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Appendix VIII <br /> Un erground Storage Tank <br /> Spill Con finer Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS IDi hh Certification Date <br /> l b V �`g 10/13/2020 <br /> Facility Name <br /> Sunwest Chevron <br /> Facility Address City County Zip Code <br /> 2758 W Kettleman Lane Lodi San Joaquin <br /> ENV <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> BZ Service Station Maintenance 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, West Sacramento, CA 95805 <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> Service Technician Performing Test <br /> Rob Jacobs <br /> ICC Number ICC Expiration Date <br /> 8819943 6/25/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> EMCO - 3474 4/30/2021 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used I Components) Tested <br /> Industry Standard 3 buckets <br /> Fhereby <br /> RTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> ertify that each spill container was tested in accordance with California Code of <br /> ns, title 23, division 3, chapter 16, section 2637. 1,that required supporting documentation <br /> d;and all information contained herein is accurate. l understand that test procedures shall <br /> be made available upon request by the governing authority. <br /> Service a nician Si pature Date Total # of Pages <br /> � 10/13/2020 <br /> Page 7 of 8 <br />