Laserfiche WebLink
................. .......... <br /> Appendix VIE <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION <br /> 7 Installation 1- Repair <br /> X 12 .1Month <br /> ; <br /> 1. FACILITY INFORMATION ------ ........ ................. ...................... <br /> CERS ID <br /> Test Date <br /> 2-28-2023 <br /> Facility Name ..................... <br /> Gas and Shop <br /> Facility Address City ZIP Code <br /> 1002 Frontage jRqaq__ Ripon Ca 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test —Vh'o-n-e—'- <br /> Self Serve Petroleum <br /> _J� 650 588-3088 <br /> Mailing Address <br /> 1045_Airport Blvd, S.San Francisco Ca 94080 <br /> Service Technician Performing Test <br /> Robert Neimeyer <br /> Contractor/Tank Tester License Number <br /> Gen A/Haz 1096495 <br /> ........... <br /> _.._._— <br /> ICC Number ICC Expiration Date <br /> 5248067 10-9-2023 <br /> .............---. ....... <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> 3-26-2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> .. ............. <br /> Test Procedures Used Components Tested <br /> PEI/ OPW regular, fill ts <br /> 6, CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING 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 <br /> documentation is attached, and all information contained herein is accurate. I understand <br /> that test procedures sh911 be made available upon request by the governing authority, <br /> -�7 <br /> Service Technician Si ur Date Total # of Pages <br /> Technician tu <br /> -------- 2-28-2023 <br /> CERS = California Environmental Reporting System, ID = Identification. ICC = international Code <br /> Council <br /> Page 1 of 2 <br />