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lJnilr�ryrai_x�7t� ��fi�r�ge �i'�nk <br />��cc�l�d�il�r ��I�tt�ir�t•rl�r�t�'T��tir�g ��par� Fc�r�l� <br />TYPE OF ACTION ❑Installation ®Repair ❑ 6 Month ®36 Month <br />1.. FACILITY INFORMATION <br />CERS ID � <br />10181407 <br />Test Date <br />8161202 � <br />Facility Name . <br />Kwlk Sere Lodi <br />Facility Address <br />420 W Kettleman Lane <br />City <br />Lodi <br />County <br />San Joaquin <br />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 <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 ©ate <br />Franklin Fueling iNCON: 3000784289 <br />9/9/2021 <br />PEI RP1200-19 - 91% <br />4. TEST PROCEDURE INFORMATION <br />; ; ::. , ` <br />Test Procedures Used <br />Com onents Tested <br />pEURP1200Nacuum TesU10Hg for 1hr <br />Annular: <br />PEIiRP1200tPressure Test/5 psi for 1 hr <br />Piping: 1 sec line <br />INCON/TS1000/Hydrostatic-15min <br />SumpsiUDCs; 1 UDC <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING'T'EST'::': <br />l hereby certify that the secondary containment was tested in accordance with California Code of <br />Regu/ations, title 23, division 3, chapter I6, section 2367,• that required supporting documentation is <br />attached; and a!l information contained herein is accurate. /understand that test procedures shall <br />be made availab/e upon request by the governing authority. <br />Service Technician Signature <br />�... <br />\,����---�, � <br />Date <br />8/6/2821 <br />Total # of Pages <br />Page 1 of 6 <br />