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-- o <br /> 0 <br /> Appendix VIII n <br /> Underground Storage Tank <' <br /> Spill Container Testing Report Form 0- <br /> 0 <br /> TYPE OF ACTION ❑ Installation ❑ Repair Z 12 Month 3 <br /> rD <br /> 1. FACILITY INFORMATION <br /> CERS ID -- — Test Date <br /> 10182151 10/30/2020 <br /> - n <br /> Facility Name m <br /> Ramos Oil Company <br /> Facility Address City ZIP Code ; <br /> z <br /> 10842 S Harland Raod French Camp 95231 O <br /> 2. SERVICE TECHNICIAN INFORMATION a <br /> Company Performing the Test Phone <br /> JP Petroleum Service 916-372-5693 <br /> Mailing Address < <br /> 3065 Asante Lane West Sacramento Ca 95691 n <br /> Service Technician Performing Test <br /> Grea Kaiser <br /> Contractor/Tank Tester-License Number (D <br /> 3 <br /> 811471 <br /> ICC Number ICC Expiration Date (D' <br /> 5252318 _ 1011/2021 fA <br /> 3. TRAINING AND CERTIFICATIONS m <br /> Manufacturer and Test Equipment Training Certifications Expiration Date o <br /> OPW 212412021 a <br /> m <br /> rD <br /> 4. TEST PROCEDURE INFORMATION !A <br /> Test Procedures Used Components Tested o <br /> 3 <br /> 0 <br /> N <br /> N <br /> N <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST o <br /> N <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 Tech i ature !D�ate�,' Total#of Pages <br /> � c� <br /> CE - ali ornia nvironmental Reporting System, ID= Identification, ICC= International Code <br /> Council <br /> SOL ... M <br /> Page 1 of 2 <br />