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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION Ll Installation Ll Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CE RS ID Test Date <br />10181655 02/13/2023 <br />Facility Name <br />Chevron 372736 <br />Facility Address <br />9484 West Lane <br />City <br />Stockton <br />ZIP Code. <br />95210 <br />2. SERVICE TECHNIiCIAN INFORIUTATION <br />Company Performing the Test <br />Tanknology, Inc. <br />Phone <br />800-964-1250 <br />Mailing Address <br />11000 N Mopac Expy #500 Austin, TX 78759 <br />Service Technician Performing Test <br />Jesus Saldivar <br />Contractor/Tank Tester License Number <br />743160 <br />ICG Number ICC Expiration Date <br />8361393 06/11/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Cexfifications <br />Expiration Date <br />OPW:EVR Phase 1 <br />01/04/2025 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />industry standards <br />Components Tested <br />Spill buckets <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that each spill container was rested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 76, section 2637.7; that required supporting <br />documentation is attached; and all information contained herein is accurate. l understand <br />that rest procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />a 0 <br />Date <br />02/13/2023 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = Internatlonal Code <br />Council <br />Page 1 of 2 <br />