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Appendix Vill <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION 0 Installation 0 Repair ® 12 Month <br /> ,�'�I�ITY I�Ft]I"iMA"�It�N <br /> CERS ID Test Date <br /> r 331� IAAC) <br /> Facility Name <br /> Facility Address City ZIP Code <br /> C75 !!./ eo `• � 6 �1 �y 95207 <br /> SIIGl .w 1NI�ORMi4TIQl <br /> Company Performing the Test Phone <br /> Wayne Perry Inc. 916-646-9680 <br /> Mailing Address <br /> 30 Main Ave Suite 5, Sacramento CA 95838 <br /> Service Technician Performing Test <br /> Contractor/Tank Tester License Number <br /> 300345 <br /> ICC Number ICC Expiration Date <br /> 33 F <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Test Procedures Used Components Tested <br /> ���Tr���a���►l�.e����rr�cl�T������rA�c�I�Q�cT��Io �sT <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.f;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 Technician Signature Date Total#of Pages <br /> f. <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />