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�a0827rl w4vicv L, .4.51 --kxflm U_ �' �c� CI{ �f r4 fa 4 <br /> Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION [X Installation ❑ Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certifi atio Date <br /> Facility Name <br /> Waterloo Liquor <br /> Facility Address City County Zip Code <br /> 2512 Waterloo Rd Stockton 05 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite 1V Contractors (209) 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Drive <br /> Contractor/Tank Tester License Number <br /> 1001331- HAZ <br /> Service Technician Performing Test <br /> Gilbert Garcia <br /> ICC Number ICC Expiration Date <br /> 1864 6/26/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling Systems FFS IVR Phase Systems VR- 101 3/26/2021 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components) Tested <br /> Hydrostatic Spill Containers <br /> 5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> 1 hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations,66623,division 3, chapter 16,section 2637. 1;thatrequired supporting documentation <br /> is attached;andallinformation contained herein is accurate. /understand that testproceduresshall <br /> be made a vailable upon request by the governing authority. <br /> Service T hnician Signature Date Total # of Pages <br /> 1/14/2021 <br /> CP-RS= a i ornia Environmental Reporting System, GPH= Gallons Per Hour, ID= Identification, ICC= <br /> International Code Council <br />