Laserfiche WebLink
Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181383 11/22/2022 <br /> Facility Name <br /> George Kishida <br /> Facility Address City County Zip Code <br /> 1725 Ackerman Drive Lodi San Joaquin EMD <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> BZ Service Station Maintenance 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, West Sacramento, CA 95805 <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> Service Technician Performing Test ICC Number ICC Expiration Date <br /> Rhome Desbiens 8245558 11/21/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> OPW - 100656 3/25/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components) Tested <br /> PEI 1200-17 section 6.2 2 spill buckets <br /> 5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> /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 documentation <br /> is attached;and all information contained herein is accurate. /understand that test procedures shall <br /> be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 11/22/2022 <br /> Page 6 of 7 <br />