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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 4/28/21 <br /> Facility Name <br /> MANTECA CHEVRON <br /> Facility Address City ZIP Code <br /> 1257 W. YOSEMITE MANTECA 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> FRANZEN HILL 559-688-2977 <br /> Mailing Address <br /> 1100 N. J STREET TULARE CA 93274 <br /> Service Technician Performing Test <br /> DAVID MARTIN <br /> Contractor/Tank Tester License Number <br /> A304147 <br /> ICC Number ICC Expiration Date <br /> 5246124 8-29-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> PHIL TITE , EBW, FRANKLIN 1022923708 6-27-2022 <br /> OPW 0113458 12-12-2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> HYDROSTATIC 1 HOUR FILL SPILL CONTAINERS <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 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 Sig�atur .- - Date Total # of Pages <br /> `' 4/28/21 <br /> //2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Pagel of 2 <br />