Laserfiche WebLink
Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION El Installation ® Repair ® 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10484500 - San Joaquin EMD <br />Test Date <br />6/28/2023 <br />Facility Name <br />Arco AmPm <br />Facility Address <br />255 E Harney Lane <br />City <br />Lodi <br />ZIP Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />BZ Service Station Maintenance, Inc <br />Phone <br />916-371-2380 <br />Mailing Address <br />1041 Triangle Ct, W Sacramento, CA 95805 <br />Service Technician Performing Test <br />Rhome Desbiens <br />Contractor/Tank Tester License Number <br />433159 <br />ICC Number ICC Expiration Date <br />8245558 11/21/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW - 100656 <br />3/25/2024 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI 1200-17 section 6.2 <br />2 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 Signature <br />......................... <br />Date <br />6/28/2023 <br />Total # of Pages <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />