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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> ----]7/21/23 <br /> Facility Name <br /> H tip M MARKET <br /> Facility Address City ZIP Code <br /> 2501 JACKSON AVE � ESCALON 95320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> LC SERVICES (559)444-1730 <br /> Mailing Address <br /> 3887 N VALENTINE AVE FRESNO 93722 <br /> Service Technician Performing Test <br /> CHARLES SHRABEL <br /> Contractor/Tank Tester License Number <br /> 779267 <br /> ICC Number ICC Expiration Date <br /> 9477557 7/8/24 <br /> ( 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VR# C28984 10/24 <br /> VMI #4778 10124 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> HYDROSTATIC SPILL BUCKETS <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. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician S' nature Date Total # of Pages <br /> 7/21/23 2 <br /> CERS = California EnvironAental Reporting System, ID = Identification, ICC = International Code <br /> Council <br />