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Appendix VI 01 <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair p 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181455 11/19/2020 <br /> Facility Name <br /> Unified Grocers, Inc. <br /> Facility Address City ZIP Code <br /> 1990 Piccoli Rd. Stockton 95215 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> TAIT Environmental Services, Inc. (714) 560-8222 <br /> Mailing Address <br /> 11280 Trade Center Dr., Rancho Cordova, CA 95742 <br /> Service Technician Performing Test <br /> Jaime Jauregui <br /> Contractor/Tank Tester License Number <br /> 588098 <br /> ICC Number ICC Expiration Date <br /> 8340695 08-08-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder root B48138 09-08-2022 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitoring system is operational in accordance with California Code <br /> of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br /> documentation is attached, and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 11/19/2020 <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />