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Appendix VIII RECEIVED <br /> Underground Storage Tank JAN 0 7 <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑✓ 12 Month ENVIRONMENTAL <br /> p HEALTH DEPARTMENT <br /> 1 . FACILITY INFORMATION <br /> CERS ID 10767814 Test Date 04/21 /21 <br /> Facility Name TO KAY KW I K SERVE <br /> Facility Address 420 KETTE LMAN LANE City LOD I 95240 de <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the TestAFFORDATEST Phone <br /> 209 -744-0112 <br /> Mailing Address 416 2ND STREET GALT , CA 95632 <br /> Service Technician Performing Test DAVID WINKLER <br /> Contractor/Tank Tester License Number 08 - 1739 Ex . 3 /31 /23 <br /> ICC NumberICCICC Expiration Date '. <br /> 1 /27/22 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling - EBW & Phil Tite # 10009853708 11 /30/22 <br /> OPW # 104- 633 03/ 13 /2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> LAKE TEST ALL OPW FILL BUCKETS <br /> 3 . 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 /> 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 /> 04/21 /21 <br /> ` 2E <br /> CERS = California Environmental Reporting Sy = dentification , ICC = International Code <br /> Council JAN 0 7 2022 <br /> Page 1 of 2 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />