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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />❑✓ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID 10181401 <br />Test Date 6/25/2024 <br />Facility NameVANDE POL <br />Facility Address 351 N BECKMAN RD <br />cityLODI <br />ZIP e <br />95240 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test ECO CHEK <br />Phone <br />209-744-0112 <br />Mailing Address PO BOX 1394 Lafayette CA <br />Service Technician Performing Test Ed Stearns <br />Contractor/Tank Tester License Number 14-1760 5/30/25 <br />ICC Number <br />8883080 -UT <br />ICC Expiration Date <br />11/5/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling - EBW & Phil Tite #1009893708 <br />11/26/2024 <br />OPW #104-635 <br />3/4/2026 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />LAKE TEST <br />SPILL BUCKETS <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. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />Otte <br />Date 6/25/2024 <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 />