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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION LJ Installation D Repair R3 12 Month <br /> F. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181653 01/17/2023 <br /> Facility Name <br /> CHEVRON 201761 <br /> Facility Address City ZIP Code <br /> 1103 S.MAIN ST.PERMIT NUMB.N-3315 MANTECA 95337 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Landon Zamora <br /> CentractorlTank Tester License Number <br /> 743160 <br /> ICC Number ICC Expiration Date <br /> 9768392 06/08/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW:EVR Phase 1 02/24/2024 <br /> PEI:RP1200 06/05/2079 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tester! <br /> INDUSTRY STANDARD SB <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 2637.9; that required supporting <br /> documentation is attached; and all information contained herein is accurate, f understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 01/17/2023 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />