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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 10190529 <br />Test Date 05-23-2022 <br />Facility Name J AND L MARKET <br />Facility Address <br />8115 S EL DORADO STREET <br />City <br />FRENCH CAMP <br />ZIP Code <br />95231 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Afforda Test <br />Phone <br />209-744-0112 <br />Mailing Address 416 2nd St Galt CA 95632 <br />Service Technician Performing Test Felix Ramirez <br />Contractor/Tank Tester License Number 08-1740 5-31-23 <br />ICC Number <br />ICCICC Expiration Date <br />11/06/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling - EBW & Phil Tite #1009883708 <br />12/28/2022 <br />OPW #104634 <br />3/10/2024 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI 100 <br />LAKE TEST <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 <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 Signature <br />a <br />F���� <br />Date 05-23-2022 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />