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Appendix Vill <br /> Underground Storage Tank <br /> Spfii Container Testing Report Form <br /> TYPE OF ACTION El Installation <br /> ® Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID <br /> Test Date <br /> Facility Name 9!23!22 <br /> CRUISERS BP29 <br /> Facility Address <br /> 1137 W LATHROP City ZIP Code <br /> 2. SERVICE TECHNICIAN INFORMATION ASA NTECA 95336 <br /> Company Performing the Test <br /> LC SERVICES Phone <br /> Mailing Address (5a9) 444-1730 <br /> 3887 N VALENTWE AVE FRESNO 93722 <br /> Service Technician Performing Test <br /> CHARLES SHRABEL <br /> Contractor/Tank Tester Ricense Number <br /> 779267 <br /> -]CC Number <br /> 9477657 ICC Expiration Date <br /> 3. TRAINING AND CERTIFICATIONS 7117/24 <br /> Manufacturer and Test Equipment Training Certifications <br /> VR # C28984 Expiration Date <br /> VMf # 4778 10/22 <br /> 9/22 <br /> 4, TEST PROCEDURE INFORMATION <br /> Test Procedures Used <br /> Components Tested <br /> HYDROSTATIC SPILL BUCKETS <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN COIF DUCTING FEST <br /> hereby certify that each spill container was tested in accordance with Cal" <br /> ia <br /> Regulations, title 23, division 3, chapter 16, section 2637.9; that required suf o obi Code of <br /> ng <br /> documentation is attached; and all information contained herein is accurate. I and <br /> that test procedures shall be made available upon request by the governing author'rstand <br /> Service Technician - ' n t g ►ty. <br /> Date Total # of Pages <br /> CERS = California Environmental <br /> Council Reporting System, ID = Identification ICC = International Code <br />