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[1. FACILITY INFORMATION <br />CERS ID <br />Test Date <br />12/18120 <br />Facility Name <br />Escalon Mini Mart <br />Facility Address <br />1097 E. Yosemite Ave. <br />City <br />Escalon <br />ZIP Code <br />95320 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Donlee Pump Company <br />Phone <br />(209) 537-9396 <br />Mailing Address <br />2825 Railroad Ave. Ceres CA. 95307 <br />Service Technician Performing Test <br />Jerry Lan roll <br />Contractor/Tank Tester License Number <br />ICC Number <br />8899490 <br />ICC Expiration Date <br />7123/20222 <br />3.` TRAINING AND.CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling 1 Incon <br />112021 <br />Veeder Root <br />11/20/2020 <br />OPW <br />7/3112022 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTINGTEST <br />! hereby certify that each spill container was tested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2637.9, that required supporting <br />documentation is attached; and all information contained herein is accurate. 1 understand <br />that test procedures shall be made available upon request by the groverning'authority. <br />Service T n Signature <br />Date <br />Total # of Pages <br />CRS California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />