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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 <br />10181511 <br />Test Date <br />9/10/2021 <br />Facility Name <br />Kwik Sery Escalon <br />Facility Address <br />2501 Jackson Ave <br />City <br />Escalon <br />County <br />San Joaquin EMD <br />Zip Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />BZ Service Station Maintenance <br />Phone <br />916-371-2380 <br />Mailing Address <br />1041 Triangle Ct., West Sacramento, CA 95826 l <br />Contractor/Tank Tester License Number <br />433159 <br />Service Technician Performing Test <br />Rob Jacobs <br />ICC Number <br />8819943 <br />ICC Expiration Date <br />6/25/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling INCON: 3000784289 <br />1/24/2022 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI/RP1200/Vacuum Test/10Hg for 1 hr <br />Annular: 2 annular <br />PEI/RP1200/Pressure Test/5 psi for 1 hr <br />Piping: 3 sec lines <br />INCON/TS1000/Hydrostatic-15min <br />Sumps/UDCs: 3 STP, 2 UDC <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 upon request by the governing authority. <br />Se rvi Technician Signature <br />Date <br />9/10/2021 <br />Total # of Pages <br />Page 1 of 6 <br />