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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION El Installation El Repair Y 1 12 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Test Date <br /> 12/18/20 <br /> Facility Name <br /> Escalon Mini Mart <br /> Facility Address City ZIP Code <br /> 1097 E . Yosemite Ave . Escalon 195320 <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 /> N/A <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 / Incon 1 /2021 <br /> Veeder Root 11 /20/2020 <br /> OPW 7/31 /2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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 n Signature Date Total # of Pages <br /> C S = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council <br /> Page 1 of 2 <br />