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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 /> - FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181511 7/11/24 <br /> Facility Name <br /> H&M Market <br /> Facility Address City ZIP Code <br /> 2601 Jackson Escalon 96320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> L.C. Services 1559-444-1730 <br /> Mailing Address <br /> 3887 N Valentine <br /> Service Technician Performing Test <br /> Mark Steinhauer <br /> Contractor/Tank Tester License Number <br /> 779267 <br /> ICC Number ICC Expiration Date <br /> 8357758 2/11/25 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW EVR UST#0148614 6/16/2026 <br /> FFS EVR Phase 1 #1002993709 6/17/2025 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic 87, 91, DSL <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 m ailable upon request by the governing authority. <br /> Service Technician Sign Date Total # of Pages <br /> 7/11/24 2 <br /> WL- <br /> CERS = California Environmen(al,'eporting System, ID = Identification, ICC = International Code <br /> Council <br />