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Appendix VIII <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 <br />10180605 <br />Test Date 4/23/2024 <br />Facility Name FLAG CITY CHEVRON <br />Facility Address <br />6421 CAPITOL AVE <br />City <br />L O D 1 <br />[ZIP Code <br />95242 <br />2. SERVICE TECHNICIAN INFORMATION <br />mpany Performing the Test <br />Eco - Chek <br />r <br />Phone <br />888-500-CHEK <br />Mailing Address 3249 Mt. Diablo Ct. Lafayette , CA 94549 <br />Service Technician Performing Test Zane NImmo <br />Contractor/Tank Tester License Number 04-1676 Ex. 4/30/2025 <br />ICC Number <br />8883064 -UT <br />ICC Expiration Date <br />5/27/2025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling - EBW & Phil Tite #10009843708 <br />12/5/2024 <br />OPW #104-632 <br />3/10/2026 <br />C N I # 4386 <br />2/7/2025 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />LAKE TESTING <br />SPILL BUCKET , DRAIN VALVE AND ADAPTER <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />1 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. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature Date 4/23/2024Total # of Pages <br />-Z 2 <br />CERS =California Environmental Reporting System, ID =Identification, ICC =International Code <br />Council <br />Page 1 of 2 <br />