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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION Ll Installation Ll Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CE RS ID <br />10182331 <br />Test Date <br />01/27/2022 <br />Facility Name <br />CHEVRON 208118 N-4087-1-3 <br />Facility Address <br />3355 E. HAMMER LANE @ HOLMAN RD <br />City <br />STOCK -TON <br />ZIP Code <br />95212 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test Phone <br />Tanknology, Inc. 800-964-1250 <br />Mailing Address <br />11000 N Mopac Expy #500 Austin, TX 78759 <br />Service Technician Performing Test <br />Jesus Saldivar <br />Contractor/Tank Tester License Number <br />743160 <br />ICC Number <br />8361393 <br />IGC Expiration Date <br />06/11/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling: Phil-Tite EVR Ph 1 Systems <br />07/01/2022 <br />ICC:CA UST Service Technician <br />06/11/2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Vacuum test <br />Spill Buckets <br />5. CERTIFICATION BY SERVICE <br />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 16, section 2637.1; 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 />- <br />Service Technician Signature <br />., <br />41— <br />Date <br />01 /27/2022 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification. ICC = International Code <br />Council <br />Page 1 of 2 <br />