Laserfiche WebLink
Appendix Vlll <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 /> 1118123 <br /> Facility Name <br /> KWIK SERV LODI BW113 <br /> Facility Address City ZIP Code <br /> 420 W KETTLEMAN LANE LODI 95240 j <br /> 1 .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 /> IGC Number ICC Expiration Date <br /> 9477557 7117/24 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VR # C28984 10124 <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 /> ! 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Tech "cOnSi ature Date Total # of Pages <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br />