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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10182153 12/16/2020 <br /> Facility Name <br /> LATHROP GAS & FOOD <br /> Facility Address City ZIP Code <br /> 140 LATHROP RD LATHROP, CA 95330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> AFFORDA TEST 209-744-0112 <br /> Mailing Address <br /> 416 2ND STREET 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 ICC Expiration Date <br /> 8883080-UT 11/09/20 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root A31048 7/31/21 <br /> I ncon 1009893708 11/30/20 <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 Date Total # of Pages <br /> 112/16/2020 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 />