Laserfiche WebLink
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 />10146285 <br />08/30/22 <br />Facility Name <br />Costco #658 Tracy <br />Facility Address <br />3250 West Grant Line Rd. <br />City <br />Tracy <br />ZIP Code <br />95377 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Alltech Petro, Inc <br />Phone <br />209-559-1616 <br />Mailing Address <br />P.O. Box 4208 Sonora Ca 95370 <br />Service Technician Performing Test <br />Isaac Anderson <br />Contractor/Tank Tester License Number <br />CA 623541/09-1749 <br />ICC Number <br />8146912 <br />ICC Expiration Date <br />09/10/22 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW #100456 <br />06/02/22 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI RP -1200/ <br />87A, 87B, 87C, 91 and Unleaded Additive <br />Manufacturer <br />Fill Spill Buckets <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 <br />' <br />Date <br />08/30/22 <br />Total # of Pages <br />2 <br />CERS = California Environmento4eporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />