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CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />TYPE OF ACTION Installation Repair 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Test Date <br />Facility Name <br />Facility Address City ZIP Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test Phone <br />Mailing Address <br />Service Technician Performing Test <br />Contractor/Tank Tester License Number <br />ICC Number ICC Expiration Date <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <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 />Service Technician Signature Date Total # of Pages