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Appendix <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 <br />10844113 <br />Certification Date <br />8/18/2021 <br />Facility Name <br />Harney Lane 76 <br />Facility Address <br />141 E Harney Lane <br />City <br />Lodi <br />County <br />San Joaquin EMD <br />Zip Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />BZ Service Station Maintenance 916-371-2380 <br />Phone <br />Mailing Address <br />1041 Triangle Ct, West Sacramento, CA 95805 <br />Contractor/Tank Tester License Number <br />433159 <br />Service Technician Performing Test <br />Rhome Desbiens <br />ICC Number <br />5244364 <br />ICC Expiration Date <br />12/10/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer & Test Equipment Training Certifications <br />Expiration Date <br />OPW - 100656 <br />5/8/2022 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components) Tested <br />PEI 1200-17 section 6.2 <br />3 spill buckets <br />5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE 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 documentation <br />is attached; and all information contained herein is accurate. l understand that test procedures shall <br />be made a vailable upon request by the governing authority. <br />Service Technician Signature <br />Date <br />8/18/2021 <br />Total # of Pages <br />Page 8 of 9 <br />