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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION 0 Installation Repair ® 12 Month <br /> J�'CI�I�Y I�Ft31�M►4TIt�N <br /> CERS ID Test Date <br /> I 3 <br /> Facility Name <br /> Facility Address City ZIP Code <br /> �1C75 �,/ /� ►� `• ,, 6 �,1 .Or �i� 1� �. 95207 <br /> slllw rNl�piM !+rli <br /> Company Performing the Test Phone <br /> Wayne Perry Inc, 918-646-9880 <br /> Mailing Address <br /> 30 Main Ave Suite 5, Sacramento CA 95838 <br /> Service Technician Performing Test <br /> Contractor/Tank Tester License Number <br /> 300345 <br /> ICC Number ICC Expiration Date <br /> 2 o <br /> E3 F <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> 77, <br /> Ttat [ �lR 'I111C) MAFIQI <br /> Test Procedures Used Components Tested <br /> ���Tr���a���►l�.�����rr�cl�T���I���rA���I�Q�cTa�,o �sT <br /> I 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 Technician Signature Date Total#of Pages <br /> f. <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />