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TYPE OF ACTION <br />Appendix 11111 <br />Underground Storage Tan k <br />Spill Container Testing Report rt Form <br />X Installation <br />1. FACILITY INFORMATION <br />(;E-Kti lu <br />10182295 <br />C Repair El 12 Month <br />– — --- -Test Date <br />7117125 <br />Facility Name <br />Orlandos Market <br />Facility Address City ZIP Dc <br />18754 Hwy 28 Linden 96236 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test Phone <br />JP Petroleum Service 916-372-5693 <br />Mailing Address <br />Service Technician Performing Test <br />rtTatnk Tester License Number <br />ICC Number <br />8413'28 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certffications <br />OPW <br />Ui1111111#tn <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <br />Hydrostatic Spill Bucket <br />- - ICC Expiration Date <br />1012026 <br />Expi'rati'on Date <br />812026 <br />412027 <br />S. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that each spill container was tested in accordance with Calrformia Code of <br />Regula tions, title 23, division 3, chapter 16, section 2637.1 that required supporting <br />documentation is attached and all informa#iion contained herein is accurate. ! understand <br />that test procedures shaff be made available upon request by the governing aufhorlty. <br />Suri Tec rwioi ignare Date Total of Pages <br />�t <br />CERS = California Environmental Deporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of <br />