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3 <br />Section VI! <br />Underground Storage Tank <br />I econdary Containment Testing Report Form <br />-YPE OF ACTION El Installation Repair F 6 Month Lq 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />i Test Date <br />T_ --�� <br />2!18/2021 <br />Facility Name <br />Kwik Sery Lodi <br />Facility Address City i County <br />Zip Code <br />420 W Kettleman Lane Lodi I San Joaauin <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />I Phone <br />i BZ Service Station Maintenance <br />Mailing Address <br />916-371-2380 <br />1041 Triangle Ct., West Sacramento, CA 95826 <br />Contractor/Tank Tester License Number <br />433159 <br />Service Technician Performing Test <br />Jeff Raven and Rob Jacobs <br />ICC Number <br />ICC Expiration Date <br />9326216 exp 7/24/2023 and 8819943 exp 6/25/2022 <br />3. TRAINING AND CERTIFICATIONS <br />- <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />— — <br />Franklin Fueling INCON: Jeff Raven - 1016313710 <br />10/20/2022 <br />Rob Jacobs - 3000784289 <br />9/9/2021 <br />------ ----- <br />Rob Jacobs - PEI RP1200-19 - 91 % <br />-- - - --- <br />4. TEST PRO_ CEDILIRE INFORMATION <br />_ <br />Test Procedures Used <br />_ <br />Components Tested <br />Annular: <br />PEI/RP1200fVacuum Test/10Hg for 1 hr <br />Piping: 2 sec lines <br />Sumps/UDCs: 1 STP, 3 UDC <br />PEI/RP1200/Pressure Test/5 psi for 1hr <br />INCON/TS1000/Hydrostatic -15min <br />j 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />`— <br />/hereby certify that the secondary containment was tested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2367,- that required supporting documentation is <br />attached; and all information contained herein is accurate. l understand that test procedures shall <br />be made available upon request by the governing authority. <br />Service Technician SignaturT Date <br />8/6/2021 <br />Total # of Pages <br />I�T � Page 1 of 6 <br />