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Appendix W1 <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION El Installation [] Repair ® 12 Month <br /> 1. FACILITY INFORMATRO—N <br /> E s I� - — _- <br /> 10181383 - San Joaquin EMD Test Date <br /> Facility tVame _ _ 111 41 025 <br /> GaleOf a Ki <br /> � _Shida <br /> " Ackerman Dr I <br /> ty <br /> . SERVICE TECHNi IAN INFpR INFORMATION ---- Loci f f� Code <br /> COmp Parr, er€a+�r�irr~ -� ON 9524 <br /> Se+'++ice g g the Test - —-- <br /> tio9 Maintenance, inc <br /> Mailing Ad[fress I Phony <br /> 1041 Trfan le Ct, W Sacrarrmento 1916-371- ,360 <br /> Service Technician Performing Tes A 580 <br /> Rho Desbiens <br /> Con#ractorlTank Tester License dumber <br /> 4331 9 <br /> ICC Number _ _ <br /> 8246658 = --- <br /> I TRAINING AND C � -- ----- _ __ I Expiration Dale <br /> h1ar?t,facft�rerartd Test Equip ATIONS --- 14J2 1 026 <br /> SPIN- 10 Equip Train#?g Cer��h frons <br /> 56 <br /> Expiratiorr Date <br /> i <br /> -- _ 13l6f206 <br /> 4. <br /> WonjUTIO <br /> 7 ( dares Used - --- IY ~ - -- <br /> PE' 1200;19 P14.17 °'nAonen S Tesw <br /> 2 spill buckets <br /> T11 ICATI N By SERVE �- - <br /> _ I <br /> l hereb ce CI<Tec'iiNtr�1N C1DIr! - <br /> rtif that each s CTIN 7 ST - - - <br /> 1?6 uldteorrs, title pit!corrtairxer was Tested in eccordanc With y - - - - - - J <br /> dcctr 2 • dvfsion 3, chapter TB, sectivr� 26T. <br /> tatiorr is adache "OrniO Code of <br /> that lost procedures shall b+e rrtad!!i formation co tair�ed ' tha#required su <br /> I� rlir�g <br /> Service TeCbnir_iarr S' a available Lr bereir� is accurate. l crnders <br /> +mature -� arr regtes#by the ova ter+d <br /> � rng authority. <br /> Date - <br /> ?1/24/2025 Total# of Pages_R � California 1~nvirOnMentat Reporting 2 <br /> )until stem, I - -- <br /> Identitwcatron. ICC � international Code <br />