Laserfiche WebLink
Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation ❑ Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10180541 <br />Certification Date <br />01-07-2021 <br />Facility Name <br />JOE'S TRAVEL PLAZA - AUTO SIDE <br />Facility Address <br />15600 S HARLAN RD <br />City <br />LATHROP, CA <br />ZIP Code <br />95330 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />AFFORDA TEST <br />Phone <br />209-744-0112 <br />Mailing Address <br />416 2ND STREET GALT, CA 95632 <br />Service Technician Performing Test <br />FELIX RAMIREZ <br />Contractor/Tank Tester License Number <br />08-1740 Ex.3/31/23 <br />ICC Number <br />8883072 -UT <br />ICC Expiration Date <br />11/22/22 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root 834976 <br />7/8/22 <br />I ncon 1009883708 <br />11/30/22 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I 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 <br />�r C 101-07-2021 <br />Date <br />Total # of Pages <br />6 <br />CERS = California Environmental Reporting S) <br />ICC = International Code Council, LLD = Line I <br />Walled, UDC = Under -Dispenser Containment, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Stem, GPH = Gallons Per Hour, ID = Identification, <br />eak Detector, NA = Not Applicable, SW = Single - <br />UST = Underground Storage Tank, <br />Page 1 of 6 <br />