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Z7)0 kart \III <br />Undergrouncl Storage Tank <br />econdaiy Containment Testing Report Forrn <br />TYPE OF ACTION p Installation ® Repair ❑ 6 Month 0 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181407 <br />Test Date <br />6/16/2021 <br />Facility Name <br />Kwik Sery 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 Date <br />Franklin Fueling INCON: 3000784289 <br />9/9/2021 <br />PEI RP1200-19 - 91% <br />4% TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Com onents Tested <br />PEI/RP1200fVacuum Test/10Hg for 1 h <br />Annular: <br />PEI/RP1200/Pressure Test/5 psi for 1 hr <br />Piping: 1 sec line <br />INCON/TS1000/Hydrostatic -15min <br />Sumps/UDCs: 1 STP, 2 UDC <br />_ 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING EST <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 contalned herein is accurate. / understand that test procedures shall <br />be made available upon request by the governing authority. <br />Service Technician Signature <br />\/ ,/\ -w <br />Date <br />6/16/2021 <br />Total # of Pages <br />