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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION O Installation _ Repair V 12 I'donth <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181657 01/13/2021 <br /> FacilitName <br /> CHEVRON#201383(N-2515-1-1) <br /> Facility Address Cite ZIP Code <br /> 1960 W.1 TH STREET @ CORRAL HOLLOW TRA 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailin�q Address <br /> 11000 N opac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Brent Bowen <br /> Contractorgank Tester License Number <br /> 743160 <br /> ICC Number ICC Expiration Date <br /> 8211862 06/17/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC:Vapor Recovery System Testing&Repair 10/27/2022 <br /> OPW:EVR Phase 1 01/05/2022 <br /> ICC:CA UST Service Technician 06/17/2021 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tester! <br /> Vacum test Opw spill buckets <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was rested in accordance with California Code of <br /> Regulations, rifle 23, division 3, chapter 96, section 2637.9; that required supporting <br /> documentation is attached;and all information contained herein is accurate. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total# of Pages <br /> zl�' -Alr— 1/13/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />