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Received by EHD via email from <br /> Glenn Paredes: Appendix VIII <br /> 10/18/2022 Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION X Installation ❑ Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CER S ID Test Date <br /> 10902574 9-14-2022 <br /> Facility Name <br /> Safeway#5816 <br /> Facility Address City ZIP Code <br /> 19533 S. Mountain House CA 95391 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> B&T Service Station Contractors 805-929-8944 <br /> Mailing Address <br /> 630 S. Frontage Rd Nipomo <br /> Service Technician Performing Test <br /> Les Henderson <br /> Contractor/Tank Tester License Number <br /> 902034 <br /> ICC Number ICC Expiration Date <br /> 5250415 03.27.2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW - 1193931 07.25.2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> RP1200 <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 documentation is <br /> attached, and all information contained herein is accurate. I understand that test procedures shall be <br /> made available upon request by the governing authority. <br /> Service TechniciaS.gnatu Date Total # of Pages <br /> 9-14-2022 2 <br /> �--� <br /> 6. SPILL CONTAINER DETAILS <br /> Test Method Developed by ❑ Manufacturer ® Industry Standard ❑ Professional Engineer <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />