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Appendix VIII <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 Test Date <br /> 10844113 - San Joaquin EMD 7/12/2023 <br /> Facility Name <br /> Harney Lane 76 <br /> Facility Address City ZIP Code <br /> 141 E Harney Lane Lodi <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> BZ Service Station Maintenance, Inc 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, W Sacramento, CA 95805 <br /> Service Technician Performing Test <br /> Jim Williams <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> ICC Number ICC Expiration Date <br /> 5252274 1/12/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW - 123509 3/22/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI 1200-17 section 6.2 3 spill buckets <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING 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 <br /> documentation is attached, and all information contained herein is accurate. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Servic echnic n Signature Date Total # of Pages <br /> 7/12/2023 <br /> CER i ornia Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />