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Appendix V! <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 /> 109 56057 05-24-2021 <br /> Facility Name <br /> UPS <br /> Facility Address City ZIP Code <br /> 1532 North Broadway Stockton 195205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> R.L Stevens Co 510-889-0908 <br /> Mailing Address <br /> P.O Box 361 San Leandro, Ca . 94577 <br /> Service Technician Performing Test <br /> David Pereira <br /> Contractor/Tank Tester License Number <br /> 415807 <br /> ICC Number ICC Expiration Date <br /> 5240739 07-28-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root 01-07-2022 <br /> Vaporless LDT-890 06.11-2021 <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 2636; that required supporting <br /> documentation is attached;and all information contained herein is accurate. <br /> ServiceTe n Signature Date Total # of Pages <br /> 06-24-2021 10 <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 />