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Appendix 8 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TESTING TYPE a lnstalia6on CK Repair ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> EFTS ID Test Date <br /> 1018138 San Joaquin EMD 311 120 6 <br /> Facility Name - - <br /> George kishida <br /> Facility Address City ZIP Code <br /> 1725 Ackerman Dr Lodi 95240 <br /> . SERVICE TECHNICIAN INFORMATION <br /> Company Performing Testing 'hone <br /> BZ Service Station Maintenance I N+; 1(916) 371-2380 <br /> Mailing Address <br /> PO Box 933, W Sacramento, CA 96691 <br /> Service Technician Performing Testing <br /> Jeff Raven <br /> Contractor License Number —433159 <br /> ICC Certification --- — - — ICC Expiration Date <br /> 19326216 6128/2027 <br /> 3. TRAINING AND CERTIFIC TION <br /> Manufacturer and Test Equipment Training Certifications Training Expiration Date <br /> Franklin Fueling INCON. 1016313710 2/412027 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI-RP1 00-VA -10Hg/1hr Annular. _ <br /> PEI-RP 1 DO-Press-6psi1#hr Piping: <br /> INCON-TS1000-Hyd-16rnin umpslUD s: 1 STP - <br /> S. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> r! hereby certify that the secondary containment was tested in accordance with California <br /> Code of Regulations, tale 23., division 3, chapter 16, section 2666; that required supporting <br /> documentation is af#ached;and all information contained herein is accurate. ! understand <br /> that test procedures must be made available upon request by the governing authority. <br /> e o ech icia i r�atcre - Dante Total # of Pages <br /> L. /13/2026 <br /> CERU L talifornia Environrrrental Reporting System, ICC R International Code Council, <br /> ID ;-- Identification, NA = Not Applicable, UDC - Under-Dispenser Containment <br /> Page 1 of 4 <br />