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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation D Repair <br />❑ 12 Month <br />00010 <br />1. FACILITY INFORMATION <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 = <br />CERS ID <br />10181541 <br />Certification Date <br />11/19/2021 <br />Facility Name <br />Pacific Bell Telephone Co. dba AT&T California <br />Facility Address <br />1812 Coley Ave. <br />City <br />Escalon <br />ZIP Code <br />95320 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />TAIT Environmental Services, Inc. <br />Phone <br />(714) 560-8222 <br />Mailing Address <br />11280 Trade Center Dr., Rancho Cordova, CA 95742 <br />Service Technician Performing Test <br />Craig Feezell <br />Contractor/Tank Tester License Number <br />588098 <br />ICC Number <br />8374133 <br />ICC Expiration Date <br />06-09-2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root <br />06A 3-2021 <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 />G J 7w�� <br />Date <br />11/19/2021 <br />Total # of Pages <br />Walled, UDC UDC = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />