Laserfiche WebLink
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 10180661 Test Date 12/15/2020 <br /> Facility Name ONE STOP MARKET <br /> Facility Address 1151 W LO U I S E AVE City MANTECA, CA ZIP Code <br /> 85336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the TestAFFORDATEST Phone <br /> 209-744-0112 <br /> Mailing Address 416 2ND STREET GALT, CA 95632 <br /> Service Technician Performing Test DAVID WI N KLE R <br /> Contractor/Tank Tester License Number 08-1739 Ex. 3/31 /23 <br /> ICC Number ICC Expiration Date <br /> 8883059-UT 1/27/22 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root B34975 2/7/22 <br /> Incon 1009853708 11/30/20 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> LAKE TEST ALL OPW FILL BUCKETS <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. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Si nature Date Total # of Pages <br /> w 12/15/2020 6 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />