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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 Certification Date <br />10180831 7/9/2021 <br />Facility Name <br />STOP N SHOP <br />Facility Address 0OCKTON <br />y ZIP Code <br />1856 COUNTRY CLUB BLVD 95204 <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 St Galt CA 95632 <br />Service Technician Performing Test <br />Edward Stearns <br />Contractor/Tank Tester License Number <br />14-1760 Ex. 9/30/23 <br />ICC Number <br />8883080 -UT <br />ICC Expiration Date <br />11/6/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root A31048 <br />7/31/21 <br />Incon 1009893708 <br />3/1/2023 <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 />� 0 17/9/2021 <br />Date <br />Total # of Pages <br />6 <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 />