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Section \A <br />Underground Storage Yank <br />Report Form <br />Secondary Containment 0 6tM9 th R® 36 Month <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />1. FACILITY INFORMATION <br />CERS ID <br />1 Facility Name <br />Test Date <br />71212021 <br />Count Zip Code <br />Facility Address City San Joaquin EMD <br />8660 Lower Sacramento Rd Stockton <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 />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI/RP1200/Vacuum Test/10Hg for 1 hr <br />Annular: 3 annular <br />PEI/RP1200/Pressure Test/5 psi for 1 h <br />Piping: 3 sec lines <br />INCON/TS1000/Hydrostatic -15min <br />Sumps/UDCs: 3 STP, 4 UDC <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />/hereby cert/fy that the secondary containment was tested i17 aCColdi mce with G'2/i,(bmi2 Code of <br />Regulations, title 23, division 3, chapter 16, section 2367, thatrequiredsupporting documentation is <br />attached,* and all information contained herein is accurate. / understand that testproceofshall <br />be made avai/ab/e upon requestby the governing authority <br />Servic Te hnician Signature Date <br />7/2/2021 Total # of Pages <br />