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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> "TYPE OF ACTION L-1 Installation L: Repair 12 Montt <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10165883 12/15/2021 <br /> Facility Name <br /> 7-ELEVEN#20632,MKT 2368 <br /> Facility Address CZIP Cade <br /> 4627 DA NCI DR @ MARCH LN ISOUKTON 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology,Inc. 800-964-1250 <br /> MailinMq Address <br /> 11000 N opac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Landon Zamora <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> IC'C Number ICC Expiration Date <br /> 9768392 06/08/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> PEI:RP1200 06/05/2079 <br /> 4, TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tester! <br /> INDUSTRY STANDARD SPILL BUCKETS <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby ceriffy that each spifl container was rested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1; that required supporting <br /> documentation is attached;and all information contained herein is accurate. I understand <br /> that test procedures shag be made available upon request by the governing authority. <br /> Service Technician Signature Date Total# of Pages <br /> 12/15/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />