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Appendix 1!111 <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 /> Facility Address City ZIP Code <br /> r7*0 e , 1e--�,xra Avg: b6 <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 /> Jerry Lancirell <br /> Contractor/Tank Tester License Number <br /> NIA <br /> ICC Number ICC Expiration Date <br /> 8899490 7/23/20222 <br /> 3. TRAINING.AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling 1 Incon 112021 <br /> Veeder Root 1112012020 <br /> OPW 7/31/2022 <br /> 4, TEST PROCEDUREINFORMATION <br /> Test Procedures Used Components Tested <br /> 5. CER1"IFICATION DY.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 96, section 2637.9; 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 T id n ignature Date Total # of Pages <br /> Sl 6/z, <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />