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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10156057 05-29-2024 <br /> Facility Name <br /> UPS <br /> Facility Address City ZIP Cade <br /> 1532 North Broadway Stockton 195205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> RL Stevens Co 510-889-1908 <br /> Mailing Address <br /> P.O. Box 361 San Leandro CA 94577 _. <br /> Service Technician Performing Test <br /> David Pereira <br /> ContractorTFank Tester License Number <br /> . 415887 _ <br /> ICC Number ICC Expiration Date <br /> 5240739 07127/2424 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST 08/0112424 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> HydrostaticlPEI 1200 Spill bucket <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify than each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2537.1; that required supporting <br /> docurrr anon i ttached, and all information contained herein is accurate. 1 understand <br /> that st procedu s hall be made available upon request by the governing authority. <br /> SB Sig ature Date Total # of Pages <br /> 05-29-2024 2 <br /> C S = California E v mental Reporting System, ID - Identification, IGC = International Code <br /> Co <br /> Page 1 of 2 <br />