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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 <br />10156809 <br />Test Date <br />4/4/24 <br />Facility Name <br />Safeway 1769 <br />Facility Address <br />2802 Country Club Blvd <br />City <br />Stockton <br />ZIP Code <br />95204 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Service Station Systems <br />Phone <br />(408) 971-2445 <br />Mailing Address <br />680 Quinn Ave San Jose CA 95112 <br />Service Technician Performing Test <br />Stephen Ingraham <br />Contractor/Tank Tester License Number <br />485184 <br />ICC Number <br />10193405 <br />ICC Expiration Date <br />3/24/26 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling # 1006623714 <br />4/1/26 <br />OPW # 1193970 <br />8/16/24 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PE11200 <br />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 />Date <br />4/4/24 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />