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SA-63559 <br /> Appendix 5 <br /> Underground Storage Tank <br /> Release Detection Equipment Testing Report Form <br /> TESTING TYPE W Installation ❑ Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> Facility Name <br /> - <br /> Facility Address City ZIP Code <br /> `/3o W Ce n jCSf rr�c 9533� <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing Testing Phone <br /> S'mI4/cs� '4 J W) .569-8 777 <br /> Mailing Addre <br /> AC k10 qr6 <br /> Se ice T chnicia P rf rming festing <br /> Contractor License Number <br /> 7o3lq <br /> ICC Certification ICC Expiration Date <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Training Expiration Date <br /> et0-�27- fS$-a�O <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that all equipment identified in this form has been tested in accordance with <br /> California Code of Regulations, title 23, division 3, chapter 16, section 2663; that required <br /> supporting documentation is attached;and all information contained herein is accurate. <br /> Se e Si ature Date Total # of Pages <br /> CER = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, UDC = Under- <br /> Dispenser Containment, UST = Underground Storage Tank, VPH = Vacuum/Pressure/Hydrostatic <br /> Paget of 6 <br />