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Appendix Vlll <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> 'TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CER S ID Test Date <br /> 2/3125 <br /> Facility Name <br /> MANTECA CHEVRON <br /> Facility Address City ZIP Code <br /> 1257 W YOSEMITE MANTECA► 95337 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> FRANZEN HILL ( 59) 688-2977 <br /> Mailing Address <br /> 1100 N J STREET <br /> Service Technician Performing Test <br /> CHARLS SHRABEL <br /> Contractor/Tank Tester License Number <br /> 304147 <br /> ICC Number ICC Expiration Date <br /> 9477557 6/23/26 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VR# C28984 9-30-26 <br /> VMI #4778 8-11-26 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> HYDROSTATIC SPILL 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 est by the governing authority. <br /> Service Technician Sign re Date Total # of Pages <br /> " /3/25 2 <br /> CERS ® California Environmental Reporting System, ID Identification, ICC International Code <br /> Council <br /> Pagel of 2 <br />