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Appendix VIIT� <br /> M 4 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form A <br /> TYPE OF ACTION • ❑ Installation � Repair ❑ 6 Month ❑ 36 Month 4 <br /> 1 . FACILITYINFORMATION <br /> CERS ID Tet D to <br /> S13 E <br /> Facility Name <br /> weA <br /> Facility Address v it ZIP Code <br /> a AV r <br /> 2 SERVICE TECHNICIAN INORMA , ION <br /> b9 F <br /> z <br /> Company Performing the Test 4hon <br /> I <br /> Mailing Address <br /> S <br /> Service Technician Performing Test <br /> Contractor/Tank Tester License Number <br /> ICC Number ICC E pir ion Date <br /> �00 42 <br /> 3 TRAINING AND `CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration, Date <br /> S <br /> 4 TEST PROCEDURE . INFORMATION <br /> Test Procedures Used Components Tested 2 <br /> S , � 17 , <br /> g <br /> 3 <br /> . .. -. 1 <br /> , . :CERTIFICATION BY ,SERVICE TECHNICIAN CONDUCTINQ TEST ; <br /> I hereby certify that the secondary containment was tested in accordance with California <br /> Code of Regulations, title 23, division 3, chapter 16, section 2637; 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 /> C Servic a nician Si a re Date Total # of Pages <br /> 1 <br /> CERS = California Environmental Reporting System , ICC = International Code Council , <br /> ID = Identification , NA = Not Applicable , UDC = Under- Dispenser Containment , <br /> Page 1 of 5 <br />