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Appendix Vl <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION fJ Installation n Repair E 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />03t17t2021 <br />Facility Name <br />CALIFORNIA STOP <br />Facility Address <br />2224 S MANTHEY ROAD <br />City <br />STOCKTON. CA <br />ZIP Code <br />95206 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />MB SERVICES <br />Phone <br />707-4393778 <br />I Mailing Address <br />I po eox 1299 sutsuN crrY. cA 94s20 <br />Service Technician Performing Test <br />I enraru DUNAHAY <br />I Contractor/Tank Tester License Number <br />I| 945643 <br />t <br />t_ <br />a <br />CERS = California Environmental Reporting System, GPH = Gallons Per Hour, lD = ldentification, <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/HVdrostatic <br />Paqe 1 of 6 <br />Date <br />03t17t2021 <br />Total # of Paqes <br />6i <br />I ibc ruum <br />L_ry=roI <br />;__ <br />vMt #3498 <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 />I Service Technician Signature <br />Expiration Date <br />03108t2023 <br />03t13t2022