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Appendix V111 <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 Certification Date <br /> 1/13/2021 <br /> Facility Name <br /> CRM Pacific Ave Chevron <br /> Facility Address 7---- - <br /> City County Zip Code <br /> 6633 Pacific Ave Stockton San Joaquin ENV <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> BZ Service Station Maintenance 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, West Sacramento, CA 95805 <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> Service Technician Performing Test <br /> Jim Williams <br /> ICC Number ICC Expiration Date <br /> 5252274 2/11/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> FFS Philtite - 1724503701 4/9/2021 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components) Tested <br /> PEI 1200-17 section 6.2 3 spill buckets <br /> 5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> I hereby certify that each spill container was tested in accordance with California Code or <br /> Regulations, tit/e 23, division 3, chapter 16, section 2637 1;that required supporting documentation <br /> is attached;and a#information contained herein is accurate. /understand that test procedures shall <br /> be made available upon request by the governing authority. <br /> Service Technician Si Date Total # of Pages <br /> - <br /> 1/13/2021 <br /> Page 7 of 8 <br />