Laserfiche WebLink
Appendix Vlll 21200044 <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair [7 12 Month <br /> -1 . FACILITY INFORMATION <br /> - <br /> CERS ID Test Date <br /> 10181263 1 / 19 / 2021 <br /> Facility Name _ <br /> Arco 6080 <br /> Facility Address City ZIP Code <br /> 85 S . Louise Ave . Lathrop 95330 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Gettler - Ryan Inc . 925 - 551 - 7444 <br /> Mailing Address 6805 Sierra Court , Suite G , Dublin , CA 94568 <br /> - <br /> Service Technician Performing Test <br /> Darnell Smith <br /> Contractor/Tank Tester License Number 220793 <br /> ICC Number ICC Expiration Date <br /> 8709494 11112312021 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Tech Cert # 0174705 7 / 6 / 2022 <br /> PW <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> 1 Hour 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 96, section 2637. 9; 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 it of Pages <br /> 1 / 19 / 2021 2 <br /> r <br /> CERS = California Environmental Reporting System , ID = Identification , ICC - International Code <br /> Council <br /> Page 1 of 2 <br /> i <br />