Laserfiche WebLink
Appendix 5 <br />Underground Storage Tank <br />Release Detection Equipment Testing Report Form <br />TESTING TYPE ❑ Installation ❑ Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Test Date <br />10180593 <br />01/06/26 <br />Facility Name <br />MONT FUEL ALEL FOOD MART <br />Facility Address <br />City <br />ZIP Code <br />1001 E YOSEMITE AVE <br />MANTECA <br />95336 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing Testing <br />Phone <br />Norcal Petroleum Tank Testing <br />209-737-8378 <br />Mailing Address <br />877 Bateman Way Galt CA 95632 <br />Service Technician Performing Testing <br />David Winkler <br />Contractor License Number <br />1115912 <br />ICC Certification <br />ICC Expiration Date <br />8883059 -UT <br />01/30/2026 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Training Expiration Date <br />Veeder Root B34975 <br />01/28/26 <br />Incon 1009853708 <br />12/9/26 <br />VMI 2529 <br />11/11/27 <br />Bravo 2024-2929502 <br />1/19/27 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that all equipment identified in this form has been tested in accordance with <br />California Code of Regulations, title 23, division 3, chapter 16, section 2663; that required <br />supporting documentation is attached, and all information contained herein is accurate. <br />Service Technician Signature .. 'r_ Date Total # of Pages <br />T7GLUY.C� 4�.�-r 01/06/26 6 <br />CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br />ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, UDC = Under - <br />Dispenser Containment, UST = Underground Storage Tank, VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />