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Appendix 5 <br /> Underground Storage Tank <br /> Release Detection Equipment Testing Report Form <br /> TESTING TYPE ❑ Installation 0 Repair 0 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10180797 103/0912026 <br /> Facility Name <br /> Quik Stop #031 <br /> Facility Address City ZIP Code <br /> 2285 E. Fremont St, Stockton 95205 <br /> . SERVICE TECHNICIAN INFORMATION <br /> Company Performing Testing Phone <br /> Efite IV Contractors (209)-461- 3 7 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton, CA. 95205 <br /> Service Technician Performing Testing - T <br /> Ernesto E=squeda Jr. <br /> Contractor License Number <br /> 1001331-A <br /> ICC Certification ICC Expirabon Date <br /> 110399647 0311912027 <br /> 3. TRAINING AND CERTIFICATION <br /> Manufacturer and Test Equiprnent Training C e rtifica t[c ns Training Expiration Date <br /> VEeeder-Root C35659 0411212026 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> l hereby certify that all equipment identified in this form has been tesfed in accordance with <br /> Califorrxia Code at Regulations, title 23, division 3, chapter 16, seclfon 663; that required <br /> s upporting doe umentafion is attached; and all Information contained herein is accurate. <br /> Service Technician Signature Date Total# of Pages <br /> 0310912026 6 <br /> DERS ;-- California Envifcnmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council. LLD = Luxe Leak Detector, NA ;-- Not Applicable, UDG = Under- <br /> Dispenser Containment., UST = Underground Storage Tank, VPH = VacuumlPressurelHydrostatic <br /> Page 1 of 6 <br />