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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION Ll Installation J Repair 0 12 Month <br /> 1, FACILITY INFORMATION <br /> GERS ID Test Date <br /> 10181335 02/10/2022 <br /> Facility Name <br /> CHEVRON#94275 <br /> FaciI4 Address City ZIP Code <br /> 2905 W.BENJAMIN HOLT @ 1-5 STOCKTON 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Cempany Performing the Test 1 Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin,TX 78759 <br /> Service Technician Pet-forming Test <br /> Jesus Saldivar <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> ICC Number IGC Expiration Date <br /> 8361393 06/11/2023 <br /> 3. TRAINING ANIS CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW:EVR Phase 1 11/23/2022 <br /> ICC:CA UST Service Technician 06/11/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum test Spill Buckets <br /> . CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> !hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 18, section 2637.fi, that required supporting) <br /> documentation is arrached; and all information contained herein is accurate. l understand <br /> that res r pro cedures shall be made available upon request by the governing authority, <br /> Service Technician Signature Date Total # of Pages <br /> 02/10/2022 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />