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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CERS ID 10184191 Test Date 11/18/2025 <br />Facility Name & A GAS & FOOD MART <br />Facility Address 1330 E. YOSEMITE AVENUE City MANTECA ZIP Code <br />95336 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />ECO - CHEK COMPLIANCE INC. <br />Phone <br />888-500-CHEK <br />Mailing Address P.O BOX 1394 LAFAYETTE, CA 94549 <br />Service Technician Performing Test Zane NIf71mo <br />Contractor/Tank Tester License Number 04-1676 Ex. 4/30/2028 <br />ICC Number <br />ICCICC Expiration Date <br />5/28/2027 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling - EBW & Phil Tite #10009843708 <br />12/7/2026 <br />OPW #104-632 <br />3/10/2026 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />LAKE TESTING <br />SPILL BUCKET, DRAIN VALVE AND ADAPTER <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 Si nature Date 11/18/2025 <br />- <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />