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Appendix lull <br /> Underground Storage Tank <br /> Spill Container Tasting 1),oport Form <br /> TYPE OF ACTION ® Installation ® Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181401 07/18/2023 <br /> Facility Name <br /> Van De Pol ENT 1 Pacific Pride <br /> Facility Address City County Zip Code <br /> 351 N. Beckmen Rd Lodi San Joa uin 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite IV Contractors 209 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr Stockton CA <br /> Contractor/Tank Tester License <br /> Number 1001331 <br /> Service Technician Performing Test <br /> Benjamin Malaspina <br /> ICC Number ICC Expiration Date <br /> 9519380 06/17/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer S Test Equipment Training Certifications Expiration Date <br /> OPW EVR UST 182799 06/03/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components) Tested <br /> Hydrostatic Red Diesel Spill Container <br /> 5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> 1 hereby certify that each spill container was tested in accordance with Califomia Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1;#?at required supporting documentation <br /> Is attached;andallinformatlon contained herein is accurate. I understand that test procedures shall <br /> be made available upon request by the goveming authority. <br /> Service Technician Signature Date Total # of Pages <br /> Z� 07/18/2023 2 <br /> CERS= California Environmental Reporting System, GPH= Gallons Per Hour, ID= Identification, ICC= <br /> International Code Council <br />