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Appendix loll <br />Underground Storage Tank <br />Spill ContainerTesting Report Form <br />TYPE OF ACTION E) Installation Lr7 Repair E] 12 Month <br />1. FACILrTY INFORMATION <br />_ <br />REFS ID <br />Test Date <br />1711712025 <br />/0844113 - San Joaquin EMD <br />_ <br />Facility Name <br />Power Rump Plaza <br />_ <br />Address City <br />QIP Cade <br />rFa—cility <br />1 E Harney Lane Lodi <br />95249 <br />. SERVICE TECHNICIAN INF=ORMATION <br />_ <br />— <br />Company Performing the Test — <br />Phone <br />BZ Service Station Maintenance, Inc <br />916-371-2388 <br />Mailing Address <br />1041 Triangle Ct, W Sacramento, DA 95805 <br />— <br />Service Technician Performing Test <br />Randy Wilkerson <br />Contractor[Tank Tester License Number <br />433159 <br />PC Number <br />ICC E; p- ration- Date <br />8822029 <br />1212712025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equ pment Trarin ng Certifications <br />Expiration Data <br />OPW -1199835 <br />1212012025 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <br />PEI 1200-19 p14-17 3 spill buckets <br />S. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TESD' <br />! hereby certify that each spill container was tested in accordance with California code of <br />Regulations, rifle 23, division 3, chapter 16, section 263 7. 1that required supporting <br />docurmemation 1s attached, and all information contairred herein is accurate. 1 understand <br />that test procedures shall be made avallabfe upon request by the goverrring authority. <br />Service T iciar Signature Date <br />Total # of Pages <br />711712025 <br />2 <br />ERS = California Environmental Reporting System, ID = identification, ]C = International bode <br />"ncil <br />Page 1 of 2 <br />