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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION Ll Installation Ll Repair R) 12 Month <br /> 1. FACILITY INFOFZMAT10N <br /> CE RS ID Test Date <br /> 10166191 02/08/2022 <br /> Facility Name <br /> 7 ELEVEN 35355 <br /> Facility Address City ZIP Code <br /> 3202 W HAMMER LANE(N-136) STOCKTON 95209 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Jesus Saldivar <br /> Contractor7ank Tester License dumber <br /> 743160 <br /> ICC Number ICC Expiration Date <br /> 8361393 06/11/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW:EVR Phase 1 11/23/2022 <br /> ICC:CA UST Service Technician 06/11/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> H2O TEST SPILL BUCKETS <br /> 1 <br /> §. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> !hereby certify that each spill container was rested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2631.7; that required supporting <br /> documentation is attached, and all information contained herein is accurate. l understand <br /> Char test procedures shall be made available upon request by rhe go verning authority. <br /> Service Technician Signature Date Total # of Pages <br /> 41— <br /> , 02/06/2022 2 <br /> CERS = California Environmental Reporting System, ID = Identification; ICC = International Code <br /> Council <br /> Page 1 of 2 <br />