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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION Ll Installation LJ Repair 0 12 Month <br /> 1. FACILITY INFORMATION <br /> CE RS ID Test Date <br /> 10166021 03/08/2023 <br /> Facility Name <br /> 7-ELEVEN#32262,MKT 2368(N-3940-1 <br /> Facility Address City ZIP Code. <br /> 2360 W GRANTLINE 1-205 OFF RAMP TRACY 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Clint Fuhrman <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> ICC Number ICG Expiration Date <br /> 9160945 05/03/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW:EVR Phase 1 05/05/2023 <br /> Tanknology Certification:Level III Spill Container Testing Certification Exam 05/18/2025 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tester <br /> hydrostatic fill spill buckets <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was rested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1; that required supporting <br /> documentarian 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 Date Total# of Pages <br /> 03/08/2023 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />