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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION © Installation © Repair Fnv 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10180967 7-18-2022 <br /> Facility Name <br /> Quik Stop Market #144 <br /> Facility Address City ZIP Code <br /> 7272 West Lane Stockton 95210 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Walton Engineering 916 373 1166 <br /> Mailing Address <br /> 3900 Commerce Drive, West Sacramento <br /> Service Technician Performing Test <br /> Anthony Reyes <br /> Contractor/Tank Tester License Number <br /> 617238 <br /> ICC Number ICC Expiration Date <br /> 8293772 8-2-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Phase 1 103920 5-25-2023 <br /> FFS EVR Systems Phase 1 1003213709 3-19-2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic Spill Containers. <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 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 shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> Anthony Reyes 7-18-2022 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />