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Appendix <br />ContainerUnderground Storage Tank <br />Spill Testing Report <br />TYPE OF ACTION ❑ Installation ® Repair ❑ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10484500 <br />Certification Date <br />7/26/2021 <br />Facility Name <br />Harney Lane Arco <br />Facility Address <br />255 E HarneyLane <br />City Cou�—ty <br />Lodi San in EMD <br />Zip Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />BZ Service Station Maintenance <br />Phone <br />916-371-2380 <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 ICC Expiration Date <br />5244364 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 />Component(s) Tested <br />PEI 1200-17 section 6.2 <br />1 spill bucket <br />5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br />/ 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 all information contained herein is accurate. / understand that test procedures shall <br />be made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />7/26/2021 <br />Total # of Pages <br />Ut=Ko W Lanrornia Environmental Deporting System, GPH= Gallons Per Hour; ID= Identification, ICC- <br />International Code Council <br />