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Appendix 6 <br />Underground Storage Tank <br />Spill Containment 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 AXEL 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 />209-712-6366 <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 />01/30/26 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Training Expiration Date <br />Franklin Fueling - EBW & Phil Tite # 1009853708 <br />12/15/26 <br />OPW #104-633 <br />03/10/26 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <br />Lake Test I All Fill Buckets <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that each spill containment was tested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2664; that required supporting <br />documentation is attached, and all information contained herein is accurate. I understand <br />that test procedures must be made available upon request by the aovernina authoritv. <br />Service Technician Signature I Date Total # of Pages <br />b�vtirJ <br />01 /06/26 � 2 <br />CERS = California Environmental Reporting System, ICC = International Code Council, <br />ID = Identification <br />Page 1 of 2 <br />