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Appendix Ix <br />Underground Storage Tank <br />Report Form <br />Overfill Prevention Equipment RR pair ❑ 36 Month <br />TYPE OF ACTION ❑ Installation <br />1. FACILITY INFORMATION <br />CERS ID <br />10844113 <br />Facility Name <br />Harney Lane 76 <br />Facility Address <br />141 E Harney Lane <br />CityI County <br />Lodi San Joaquin EMD <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />BZ Service Station Maintenance <br />Mailing Address <br />1041 Triangle Ct., West Sacramento, CA 95826 <br />Contractor/ Tank Tester License Number <br />Inspection Date <br />2128/2022 <br />Zip Code <br />Phone <br />916-371-2380 <br />4331ow <br />Service Technician Performing Inspection <br />Rhome Desbiens <br />ICC Number Expiration Date <br />8245558 12/10/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW - 100656 <br />5/8/2022 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />PEI 1200 Pg. 18 <br />3 drop tubes <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br />l hereby certify that the OPE was inspected in accordance with California Code of Regulations, title <br />23, division 3, chapter 16, section 2637.2; that required supporting documentation is attached; and <br />a// information contained herein is accurate. / understand that test procedures shall be made <br />available upon request by the governing authority. <br />Service Technician Signature (1z <br />Date <br />8/2022 <br />Total # of Pages <br />Page 1 of 2 <br />