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RECD MLD <br /> JUN 16 2021 <br /> Appendix Vill .. <br /> Underground Storage Tank ENVIRONMENTAL <br /> Spidi ontainer Testing Report Form HEALTH DEPARTMENT <br /> TYPE OF ACTION © Installation Repair 0 12 Month <br /> 1 . FACILITY INFORMATION -- - 1 <br /> CERS ID Test Date <br /> 4/30/2021 <br /> Facility Name <br /> My Mini Mart <br /> Facility Address City ZIP Code <br /> 1756 N Wilson Way Stockton 95205 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite IV Contractors (209) 461 -6337 <br /> Mailing Address <br /> 2535 Wigwam Drive Stockton , CA 95205 <br /> Service Technician Performing Test <br /> Michal Kennard <br /> Contractor/Tank Tester License Number <br /> 1001331 <br /> ICC Number ICC Expiration Date <br /> 4811 6/ 19/2021 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC Service Technician #5254811 6/1912021 <br /> OPW EVR UST #1047904 5123/2021 <br /> 4 . TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic 91 Spill Container <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. ! understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 4/30/2021 2 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council <br /> Page 1 of 2 <br />