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Appendix VI11 <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 /> 4/3/24 <br /> Facility Name <br /> MANTECA CHEVRON <br /> Facility Address City ZIP Code <br /> 1257 W. YO EMITE MANTECA 95337 <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 93274 <br /> Service Technician Performing Test <br /> DAVID MARTIN <br /> Contractor/Tank Tester License Number <br /> A304147 <br /> ICC Number ICC Expiration Date <br /> 5246124 8118/24 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> PHIL TITS FRANKLIN 1022923708 6/ 4/24 <br /> OPW 0113468 12/24/24 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> HYDROSTATIC DIESEL FILL <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 rewired supporting <br /> documentation is attached; and all information contained herein is accurate. I understand <br /> that test procedures shall be made availablo,(pon request by the governing authority. <br /> Service Technicia Signatu 1' Date Total #of Pages <br /> 4/3/24 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Pagel of 2 <br />