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Appendix!VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION El Installation Cl Repair 0 12 Month <br /> 1.' FACILITY. INFORMATION <br /> CERS ID Test Date <br /> 10131431 3116122 <br /> Facility Name <br /> Escalon Mini Mart <br /> Facility Address City ZIP Code <br /> 1097 E. Yosemite Ave. Escalon 96320 <br /> 2.. SERVICE;`TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Donlee Pump Company (209) 5379396 <br /> Mailing Address <br /> 2825 Railroad Ave. Ceres CA. 95307 <br /> Service Technician Performing Test <br /> Gerardo Perez <br /> ContractorlTank Tester License Number <br /> L <br /> ICC Number ICC Expiration Date <br /> 8962666 3114123 <br /> 3,`TRAINING AND CERTIFICATION <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Phil Tito 1026973710 12123123 <br /> 4. TEST PROCEDURE.INFORMAT,ION <br /> Test Procedures Used Components Tested <br /> 5. CERTIFICATION BY`SER.1110E 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 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 Technician Signature Date Total # of Pages <br /> CERS = California Environmental Reporting System, ID r Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />