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itAppendix �. <br />Underground Storage Tani <br />iiiiii III IN IN Z11111 III IIIIIIII 1111� <br />IN <br />TYPE OF ACTION ❑ Installation ❑ Functionality ❑ Repair E 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10844113 <br />Certification Date <br />7/28/2022 <br />Facility Name <br />Harney Lane 76 <br />Facility Address <br />141 E HarneyLane <br />City <br />Lodi <br />County <br />San Joa uin 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 />Brian Witus <br />ICC Number <br />9566107 <br />ICC Expiration Date <br />12/18/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer & Test Equipment Training Certifications <br />Expiration Date <br />VR TLS - C31587 <br />2/18/2024 <br />VMI LD - 5119 <br />2/28/2024 <br />4. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br />/ hereby certify that the monitoring system is operational in accordance with California Code of <br />Regulations, Title 23, division 3, chapter 16, section 2638,- that required supporting documentation <br />is att hed,- and a# information contained herein is accurate. <br />Se a ature <br />Ste <br />Date <br />7/28/2022 <br />Total # of Pages <br />C1ERS='Carnia Environmental Reporting System, GPH= Gallons Per Hour, ID= identification, ICC= <br />International Code Council, LLD= Leak Line Detector, NA= Not Applicable, SW= Single Walled, <br />UDC= Under Dispenser Containment, UST= Underground Storage Tank, VPH= <br />Vacuum/Pressure/Hydrostatic <br />Page 1 of 9 <br />