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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION U Installation I Repair V 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Test Date <br />11/08/2021 <br />Facility Name <br />Stockton <br />Facility Address <br />1990 Picc li Road <br />Gita <br />Stoc on <br />ZIP Code <br />95215 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test Phone <br />Tanknology, Inc. 800-964-1250 <br />Mailing Address <br />11000 N pac Expy #500 Austin, TX 78759 <br />Service Technician Performing Test <br />Brent Bowen <br />ContractorlTank Tester License Number <br />743160 <br />ICG Number <br />8211862 <br />ICC Expiration Date <br />06/08/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />ICC:CA UST Service Technician <br />06/08/2023 <br />ICC:ICC UST Tank Tightness Testing <br />06/22/2023 <br />OPW:EVR Phase 1 <br />01/05/2022 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <br />Lake test Opw spill bucket <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />1 hereby certify that each spill container was rested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 96, section 2637.9; that required supporting <br />documentation is attached; and all information contained herein is accurate. l understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />11/08/2021 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Cade <br />Council <br />Page 1 of 2 <br />