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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing porfi Form <br /> TYPE OF ACTION ❑Installation ❑Repair 012 Month <br /> w <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 04/11/2023 <br /> Facility Name <br /> Manteca Chevron W.O. 170702 <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 /> JUNIOR SINCO <br /> Contractor/Tank Tester License Number <br /> A304147 <br /> ICC Number ICC Expiration Date <br /> 5246152 10/17/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> PHIL TITE 1011663708 05/14/23 <br /> OPW 901664 12/29/2024 <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 16, section 2637.1;that required supporting documentation is <br /> attached;and all information contained herein is accurate./understand that test procedures shall be <br /> made available upon equest by the governing authority. <br /> Service Tech ician gnature Date Total #of Pages <br /> 04/11/2023 2 <br /> 6. SPILL NTAINER DETAILS <br /> Test Methbd Developed by ❑ Manufacturer ® Industry Standard ❑ Professional Engineer <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />