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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION Ll Installation LJ Repair R) 12 Month <br /> 1. FACILITY INFORMATION <br /> CE RS ID Test Date <br /> 10165823 07/18/2023 <br /> Facility Name <br /> 7-ELEVEN#17647, MKT 2368 (N-744) <br /> Facility Address City ZIP Cade <br /> 1048 W.YOSEMITE AVE @ EL PORTEL MANTECA 95336 <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 /> Jesus Saldivar <br /> Contractor/Tank Tester License dumber <br /> 743160 <br /> ICC Number ICC Expiration Date <br /> 8361393 05/16/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW:EVR Phase 1 01/04/2025 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum test Spill Buckets <br /> 1 <br /> §. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> !hereby certify that each spill container was rested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2631.7; that required supporting <br /> documentation is attached, and all information contained herein is accurate. l understand <br /> Char test proc e du res shall be made available upon request by rhe governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> //1 07/18/2023 2 <br /> CERS = California Environmental Reporting System, ID = Identification; ICC = international Code <br /> Council <br /> Page 1 of 2 <br />