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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION Z Installation ❑ Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 1130124 <br /> Facility Name <br /> RIPON SHELL <br /> Facility Address City ZIP Code <br /> 710 JACK TONE RD RIPON <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> LC SERVICES 559-444-1730 <br /> Mailing Address <br /> 3887 N VALENTINE <br /> Service Technician Performing Test <br /> JESUS ALVAREZ <br /> Contractor/Tank Tester License Number <br /> 779267 <br /> ICC Number ICC Expiration Date <br /> 9153991 4125 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS PRO EVR PHASE 1 #1008533711 9/25 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> HYDROSTATIC BUCKETS <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 96, section 2637.1; that required supporting <br /> documentation is attached; and all information contained herein is accurate. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Tec ician Signature Date Total # of Pages <br /> l <br /> 8/1 <br /> = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> ouncil <br /> Page 1 of 2 <br />