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<br />Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br /> <br />Page 1 of 2 <br />TYPE OF ACTION ☐ Installation ☐ Repair ☐ 12 Month <br />1. FACILITY INFORMATION <br /> <br />CERS ID <br /> <br />Test Date <br /> <br /> <br />Facility Name <br /> <br /> <br />Facility Address <br /> <br />City <br /> <br />ZIP Code <br /> <br /> <br />2. SERVICE TECHNICIAN INFORMATION <br /> <br />Company Performing the Test <br /> <br />Phone <br /> <br /> <br />Mailing Address <br /> <br />Service Technician Performing Test <br /> <br />Contractor/Tank Tester License Number <br /> <br /> <br />ICC Number <br /> <br />ICC Expiration Date <br /> <br /> <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br /> <br /> <br /> <br /> <br />4. TEST PROCEDURE INFORMATION <br /> <br />Test Procedures Used Components Tested <br /> <br /> <br /> <br /> <br />5. 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 /> <br />Service Technician Signature Date <br /> <br />Total # of Pages <br /> <br /> <br />10456027 03/18/21 <br /> TRACY 76 <br /> 2420 W GRANTLINE RD TRACY 95376 <br />AFFORDA TEST 209-744-0112 <br />416 2ND STREET GALT, CA 95632 <br />DAVID WINKLER <br />08-1739 Ex.3/31/23 <br />8883059-UT 1/27/22 <br />Franklin Fueling - EBW & Phil Tite #10009853708 11/30/22 <br />OPW #104-633 03/13/2022 <br />LAKE TEST ALL OPW FILL BUCKETS <br />03/18/21 <br />2 <br />✔