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Appendix VIII <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 /> 10397599 11/14/22 <br /> Facility Name <br /> Sutter Tracy Community Hospital <br /> Facility Address City ZIP Code <br /> 1420 N. Tracy Blvd. Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Alltech Petro, Inc 209-532-7320 <br /> Mailing Address <br /> P.O. Box 4208 Sonora Ca 95370 <br /> Service Technician Performing Test <br /> Matt Hughes <br /> Contractor/Tank Tester License Number <br /> CA 623541/09-1749 <br /> ICC Number ICC Expiration Date <br /> 8889640 07/28/23 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW #0175440 10/17/24 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI RP 1200/Manufacturer Red Diesel Fill Spill Bucket <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> lI 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 /> 11/14/22 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />