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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 0 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10926289 6/16/2025 <br /> 7 <br /> Facility Name <br /> Mountain House Chevron <br /> Facility Address City ZIP Code <br /> 1124 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 /> 176 Wyoming St., Pleasanton <br /> Service Technician Performing Test <br /> Dustin Terry <br /> Contractor/Tank Tester License Number <br /> 491948 <br /> ICC Number ICC Expiration Date <br /> 10134964 7/3/2026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Phase 1 UST EVR 9/28/2025 <br /> ICC Installation/Retrofitting 1034964 11/8/2026 <br /> FFS EVR Phase 1 Systems - VR - 101 1/3/2026 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> RP1200 / Lake Test 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 by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 6/16/2025 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> UN-108 www.unidocs.org Rev.10/01/20 Page 1 of 2 <br />