Laserfiche WebLink
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 10182153 Test Date <br /> 12/16/2020 <br /> Facility Name LATH ROP GAS & FOOD <br /> Facility Address 140 LATH ROP RD city LATHROP, CA ZIP Code <br /> 95330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the TestAFFORDATEST Phone <br /> 209-744-0112 <br /> Mailing Address 416 2ND STREET GALT, CA 95632 <br /> Service Technician Performing Test EDWARD STEARNS <br /> Contractor/Tank Tester License Number 14-1760 Ex. 9/30/23 <br /> ICC Number ICC Expiration Date <br /> 8883080-UT 11/09/20 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root A31048 7/31/21 <br /> Incon 1009893708 11/30/20 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> LAKE TEST 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. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Sianature Date Total # of Pages <br /> ' 12/16/2020 6 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />