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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 /> 10181335 01/21/2022 <br /> Facility Name <br /> Chevron #94275 <br /> Facility Address City ZIP Code <br /> 2905 West Benjamin Holt Dr Stockton 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Wayne Perry Inc. 916-646-9680 <br /> Mailing Address <br /> 30 Main Ave Suite 5, Sacramento, CA 95838 <br /> Service Technician Performing Test <br /> Dean Walker <br /> Contractor/Tank Tester License Number <br /> 300345 <br /> ICC Number ICC Expiration Date <br /> 9280239 02-19-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST 101134 03-19-2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> 5 Gal Hydrostatic - 1hr 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 16, section 2637.1; that required supporting <br /> documentation is attached; and all information contained herein is accurate. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> " vll�' 01/21/2022 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />