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Appendix Vill <br />Underground Storage Tank <br />pil I Container Testing Report Form <br />TYPE OF ACTION ❑ Installation 0 Repair -I 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10182295 <br />Facility Name <br />Crlandos Market <br />Facility Address <br />18754 Hwy 26 <br />. SERVICE TECHNICIAN INFORMATION <br />Test Date <br />7116125 <br />City ZIP Code <br />Linden 95236 <br />Company Performing the Test Phone <br />JP Petroleum Service 1 916-372-6693 <br />Mailing Address <br />Service Technician Performing Test <br />ConttactorlTank "fester Lioense Number <br />ICC Number <br />8413928 <br />0 <br />3. TRAINING ANIS CERTIFICATIONS <br />Manufacturer and -rest Equipment Training Certifications <br />OPW <br />Phil Tine <br />4. TEST PROCEDURE INFORMATION <br />Fest Procedures Used Components `bested <br />Hydrostatic Spill Bucket <br />ICC Expiration Date <br />1012026 <br />Expiration Dote <br />812026 <br />4/2027 <br />. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST' <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 />docurnentation is attached, and all information contained herein is accurate. l understand <br />that test procedures shall be made available upon request by the goveming authority. <br />Servi ec ni Signature Date Total Pages <br />GERS T California Environmental Reporting System, ID = identification, FCC International Code <br />Council <br />Page 1 of 2 <br />