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Appendix Vill <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ® Installation ❑ Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10184805 3/3/2022 <br /> Facility Name <br /> Central Gas <br /> Facility Address City ZIP Code <br /> 610 S. Cherokee Ln Lodi 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite 1V Contractors (209) 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton CA <br /> Service Technician Performing Test <br /> Adrian Rodriguez <br /> Contractor/Tank Tester License Number <br /> 1001331 <br /> ICC Number ICC Expiration Date <br /> 9914593 4/27/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST 019239 5/19/2023 <br /> UST Service Tech 9914593 4/2712023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Industry standard 87 OPW spill container <br /> Industry standard 91 OPW spill container <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division apter 16, se 'on 2637.1; that required supporting <br /> documentation is attac ; and all information ontained herein is accurate. 1 understand <br /> that test procedure hall be made availab pon request by the governing authority. <br /> Service Technici gr+a Date Total # of Pages <br /> 3/3/2022 2 <br /> C �fornia onmental Reporting System, ID = Identification, ICC = International Code <br /> Counc <br /> Page 1 of 2 <br />