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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION 0 Installation © Repair © 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10180643 <br />Certification Date <br />6/2/2021 <br />Facility Name <br />Quik Stop #125 <br />Facility Address <br />1580 W. Main St <br />City <br />Ripon <br />ZIP Code <br />95366 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Walton Engineering, Inc. <br />Phone <br />916-373-1166 <br />Mailing Address <br />P.O. Box 1025, West Sacramento, CA 95691 <br />Service Technician Performing Test <br />Maxwell Hines <br />Contractor/Tank Tester License Number <br />617238 <br />ICC Number <br />8750053 <br />ICC Expiration Date <br />10/24/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root <br />3/3/2022 <br />Vaporless <br />07/28/2022 <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 />Date <br />6/2/2021 <br />Total # of Pages <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 />