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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 Test Date <br /> 8/22/23 <br /> Facility Name <br /> Statewide Petroleum <br /> Facility Address City ZIP Code <br /> 1700 E. Yosemite Ave. Manteca 94566 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Donlee Pump Company 209-537-9396 <br /> Mailing Address <br /> 2825 Railroad Ave Ceres CA. 95307 <br /> Service Technician Performing Test <br /> Gerardo Perez <br /> Contractor/Tank Tester License Number <br /> 432089 <br /> ICC Number ICC Expiration Date <br /> 8962656 3/14/23 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root 10/23/24 <br /> OPW 168393 2/14/25 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <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 />'E 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 nature Date Total # of Pages <br /> CE - ornia Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />