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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair N 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10926289 06/28/2024 <br /> Facility Name <br /> Chevron <br /> Facility Address City ZIP Code <br /> 1124 N.International Pkwy Tracy 95377 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Central Petroleum Maintenance 925-462-4060 <br /> Mailing Address <br /> P.O.Box 211 Pleasanton Ca 94566 <br /> Service Technician Performing Test <br /> Michael Spring <br /> Contractor/Tank Tester License Number <br /> 491948 <br /> ICC Number ICC Expiration Date <br /> 8898723 11/14/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Phase 1 UST 01/12/2026 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic Spill Buckets <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />