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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 /> 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 /> Mario Romero <br /> Contractor/Tank Tester License Number <br /> 1018253 <br /> ICC Number ICC Expiration Date <br /> 8034353 1014/26 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root 215/27 <br /> OPW 5130/27 <br /> Franklin Fueling 113/27 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> � P <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 Date Total # of Pages <br /> CE = Californ Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />