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Appendix 7111 <br />SpillUnderground Storage Tank <br />Container Report <br />TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10484500 <br />Certification Date <br />6/21/2021 <br />Facility Name <br />Harney Lane Arco <br />Facility Address <br />255 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 />4 spill buckets <br />I- <br />5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br />l hereby certify that each spill container was tested in accordance with California Code of <br />Regulations, tit/e 23, division 3, chapter 16, section 2637.1, that required supporting documentation <br />is attached; and al/ information contained herein is accurate. / understand that test procedures shall <br />be made available upon request by the go verning authority. <br />Service Technician Signature <br />Date <br />6/21/2021 <br />Total # of Pages <br />Page 8 of 9 <br />