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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION U Installation Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181341 11/15/2021 <br /> Facility Name <br /> CHEVRON#99840(N31) <br /> Facility Address G11 ZIP Code <br /> 4344 E w TERLOO RD @ 99 TON 95215 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N pac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Jesus Saldivar <br /> ContractorlTank Tester License Number <br /> 743160 <br /> ICG Number IGC Expiration Date <br /> 8361393 06/11/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC:CA UST Service Technician 06/11/2023 <br /> Franklin Fueling:Phil-Tite EVR Ph 1 Systems 07/01/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum test spill buckets <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that each spill container was rested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 96, section 2637.9; that required supporting <br /> documentation is attached;and all information contained herein is accurate. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total #of Pages <br /> p 11/15/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Cade <br /> Council <br /> Page 1 of 2 <br />