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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System, (',Prrifir`gtwr)n Form <br /> TYPE OF ACTION ❑ Installation ❑ Functionality ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181383 11/18/2021 <br /> Facility Name <br /> Geor a Kishida <br /> Facility Address City Co�J�o <br /> �Zip Code <br /> 1725 Ackerman Dr Lodi Sauin EMD <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> BZ Service Station Maintenance 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, West Sacramento, CA 95805 <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> Service Technician Performing Test <br /> Rhome Desbiens <br /> ICC Number ICC Expiration Date <br /> 8245558 12/10/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> Omntec - 112111 RD 9/10/2023 <br /> VMI LD - 2906 5/20/2022 <br /> 4. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> /hereby certify that the monitoring system is operational in accordance with California Code of <br /> Regulations, Title 23, division 3, chapter 16, section 2638;that required supporting documentation <br /> is attached;and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 11/18/2021 <br /> CERS= California Environmental Reporting System, GPH= Gallons 1--(:�i -our, iu= iaei-1 LilicaLion, ICC= <br /> International Code Council, LLD= Leak Line Detector, NA= Not Applicable, SW= Single Walled, <br /> UDC= Under Dispenser Containment, UST= Underground Storage Tank, VPH= <br /> Vacuum/Pressure/Hydrostatic <br /> Page 1 of 9 <br />