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E.O. VR -201/202 <br />Dispenser Vapor Line Integrity Test Report Form <br />Permit Number: N-262 DATE 3/31/25 <br />Test Company: NOR -CAL TANK TESTING <br />Site Name: COUNTRYSIDE CHEVRON <br />Technician: DAVID WINKLER <br />Site Address: 14971 N HIGHWAY 88 <br />Certification Number Expiration Date <br />City: LODI CA <br />District: SJV 0082 03/31/26 <br />Franklin: 1009853708 01/07/27 <br />DISPENSER VAPOR LINE INTEGRITY TEST <br />Initial Vacuum After Final Vacuum After 60 Pass/Fail <br />Dispenser # Closing the Ball Valve seconds (in. H2O) (vacuum reading cannot fall <br />in. H2O more than 4 in. H2O) <br />1/2 75 73 PASS <br />3/4 75 74 PASS <br />I declare, under penalty of perjury under the laws of the state of California that based on information and belief formed <br />after reasonable inquiry, the statements and information provided in this document are true, accurate, and complete. <br />Signature of Technician: <br />3/31/25 <br />Ver. 1.3 — 08.07.09 <br />