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Appendix 11111 <br /> Underground Storage Tank <br /> Spill Container Testing Report Fore <br /> TYPE OF ACTION ® Installation ® Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10443520 05/03/2023 <br /> Facility Name <br /> Thornton Chevron <br /> Facility Address CityCounty Zip Code <br /> 9015 Walnut Grove Rd Thornton 95686 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite IV Contractors 209 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr Stockton CA <br /> Contractor/Tank Tester License <br /> Number 1001331 <br /> Service Technician Performing Test <br /> Michal Kennard <br /> ICC Number ICC Expiration Date <br /> 5254811 07/06/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> FFS Phase 1 Systems - VR-101 07/12/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Component(s) Tested <br /> Hydrostatic 91 Spill Container <br /> 5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> I hereby certify 1 hat each spill container was tested in acaardanae with Caftmia Code of <br /> Regulations, We 23, division 3, chapter 16, section 2637.1;Mat fequired supporting documentation <br /> Is attached,•and all information contained her is acowate. /understand that testpmcedures shall <br /> be made available upon request by the goveming authority. <br /> Service Technician Signature Date Total # of Pages <br /> t► 05/03/2023 2 <br /> CERS= California Environmental Reporting System, GPH= Gallons Per Hour, ID= Identification, ICC= <br /> International Code Council <br />