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Appendix VIII <br /> Underground Storage Tank <br /> Spill CoiftiFw Tesfing Report Form <br /> TYPE OF ACTION 8 Installation ❑ Repair 10 12 Month <br /> 1. FACHM T10N <br /> CERS ID Test Date <br /> �bl8i � � 11 • `� •� <br /> Facility Name 998 4U <br /> Facility Address City ZIP Code <br /> j-� y� �e�lcx� �d• S� 9-2JS <br /> 2. SERVICE rATKN+I <br /> Company Perform ng the Test Phone <br /> T �2 ) <br /> -q(-S3 <br /> Mailing <br /> Mailing Address $5oa o <br /> Service Techniciai i Performing Test <br /> 3 tsps j • sC,ld'vc&-f <br /> Contractor/Tank Tester License Number <br /> c radneer°►1 316 b <br /> ICC Number ICC Expiration Date <br /> 613 9 3 3 z► <br /> 3. TRAI CERTWICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> o <br /> 4 t -7 S ti..S 1004MA <br /> t'ZZ <br /> 4. TESTiF4tIiNAT1f�N <br /> Test Proceduressed Components Tested <br /> VC&C VU s s L cl ���e�s <br /> 5. CERTlFiCA BY SERVICE TECHNNUAN CONDUCTM TEST <br /> I hereby certify at each spill container was bested in accordance with California Code of <br /> Regulations, 23, division 3, chapter 16, section 2637.1;that required supporting <br /> documentation i attached;and aU information contained herein is accurate. I understand <br /> that test proof shall be made available upon request by the governing authority. <br /> Service Techni " Signature Date Total#of Pages <br /> //• q ." 2- <br /> CERS = Ca' is nvkwmental Reporting System, ID= Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />