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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 10180561 Test Date <br /> 12/26/2023 <br /> Facility Name ESCALON MINI MART <br /> Facility Address ZIP de <br /> 1097 YOSEMITE AVE city ESCALON 95320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Afforda Test 209-744-0112 <br /> Mailing Address4162nd St Galt CA 95632 <br /> Service Technician Performing Test Edward Stearns <br /> Contractor/Tank Tester License NumberCSLB: 958763 Lic # 14-1760 <br /> ICC Number ICC Expiration Date <br /> 8883080-UT 11/05/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root A31048 7/31/25 <br /> Incon 1009893708 11/26/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> LAKE TEST 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. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signatur�;�.�'1'l�GtrGC 9tli Date 12/26/2023 6otal # of Pages <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />