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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 10182153 <br />Test Date 12/16/25 <br />Facility NameLATHROPGAS & FOOD CHEVRON <br />Facility Address 140 LATH ROP RD <br />City LATH ROP <br />95330 ZIP de <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />NOR CAL TESTING <br />Phone <br />209-712-6366 <br />Mailing Address 877 BATEMAN WAY GALT CA 95632 <br />Service Technician Performing Test David Winkler <br />Contractor/Tank Tester License Number 08-1739 Ex.3/31 /26 <br />ICC Number <br />ICCICC Expiration Date <br />1/30/26 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW #104-633 <br />03/10/26 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />LAKE TEST <br />ALL FILL 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 Sianatw <br />ure Date 12/16/25 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />