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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑Installation ❑Repair x12 Month <br /> 1. FACILITY INFORMATION <br /> CERS 1D Test Date <br /> 10422476 03/13/2025 <br /> Facility Name <br /> Yosemite Avenue A CO AM PM <br /> Facility Address City ZIP Code <br /> 1711 E. Yosemite Ave. Manteca � 95336 <br /> 2. SERVICE TECW ICIAN INFORMATION <br /> Company Performin the Test Phone <br /> Diamond Petroleurr Services, Inc. (925)470-0803 <br /> Mailing Address <br /> 3619 King Ct A ntioc h, CA 94509 <br /> Service Technician Performing Test <br /> Guadalupe Sanche <br /> ContractorlTank Tes er License Number <br /> 1005"4 <br /> ICC Number ICC Expiration Date <br /> 6250451 04/0112025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW PHASE 1 UST EVR Tech# 0163755 06/06/2026 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI120o1Hydrost Test 87M,87S and 91 Fill Spill Buckets <br /> S. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify thai 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 documentation is <br /> attached;and all in ormation contained herein is accurate.1 understand that test procedures shall be <br /> made available upo ri request by the governing authority. <br /> Service Technician ignature Date Total # of Pages <br /> 03/1312025 2 <br /> 6. SPILL CONTAIN R DETAXS <br /> Test Method Develo ed by ❑ Manufacturer x Industry Standard ❑ Professional Engineer <br /> CERS = California nvironmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />