Laserfiche WebLink
Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair F,/ 12 Month <br /> 1 , FACILITY ,'INFORMATION <br /> CERS ID Test Date <br /> 10184829 06/20/2022 <br /> Facility Name <br /> Rancho San Miguel Market <br /> Facility Address City ZIP Code <br /> 1427 S Airport Way Stockton 95206 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Service Station Systems, Inc. (408 ) 971 -2445 <br /> Mailing Address <br /> 680 Quinn Ave , San Jose CA 95112 <br /> Service Technician Performing Test <br /> Kristopher Bell <br /> Contractor/Tank Tester License Number <br /> 485184 <br /> ICC Number ICC Expiration Date <br /> 8833000 07/28/2022 <br /> 3 . ' TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling # 1004933708 06/20/2024 <br /> OPW# 902968 06/03/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> OPW SPILL BUCKETS <br /> 5 . ' CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637. 1 ; that required supporting <br /> documentation is attached; and all information contained herein is accurate. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 06/20/2022 2 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council <br /> Page 1 of 2 <br />