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Section VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 1/15/2021 <br /> Facility Name <br /> Kwik Sery Lodi <br /> Facility Address City County Zip Code <br /> 420 W Kettleman Lane Lodi San Joaquin ENV <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> BZ Service Station Maintenance 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct., West Sacramento, CA 95826 <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> Service Technician Performing Test <br /> Jeff Raven <br /> ICC Number ICC Expiration Date <br /> 9326216 8/31/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling INCON: 1016313710 10/20/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI/RP1200/Vacuum Test/101-Ig for 1 hr Annular: 2 annular <br /> PEI/RP1200/13ressure Test/5 psi for 1 hr Piping: 2 sec lines <br /> INCON/TS1000/Hydrostatic- 15min Sumps/UDCs: 2 UDC, 3 STP <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <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 a//information contained herein is accurate. /understand that test procedures shall <br /> be made available upoqf.&qaest by the governing authority <br /> Se i echnicia ignature Date Total # of Pages <br /> 1/15/2021 <br /> Page 1 of 6 <br />