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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 10180605 Test Date 04/26 /21 <br /> Facility Name FLAG CITY CHEVRON <br /> Facility Address 6421 CAPITAL AVE City LO D I , CA ZIP <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the TestAFFORDATEST Phone <br /> 209 - 744 - 0112 <br /> Mailing Address 416 2ND STREET GALT , CA 95632 <br /> Service Technician Performing Test DAVID WINKLER <br /> Contractor/Tank Tester License Number 08 _ 1739 Ex . 3 / 31 /23 <br /> ICC Number ICC Expiration Date <br /> 8883059 - UT 1 /27/22 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling - EBW & Phil Tite # 10009853708 11 /30 /22 <br /> OPW # 104 - 633 03/ 13 /2022 <br /> 4 . TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> LAKE TEST ALL OPW FILL 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 Date 04/26/21 Total # of Pages <br /> i <br /> 2 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council <br /> Page 1 of 2 <br />