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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation ❑ Functionality ❑ Repair ® 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181511 <br />Certification Date <br />7/20/2021 <br />Facility Name <br />Kwik Sery Escalon <br />Facility Address <br />2501 Jackson Ave <br />City <br />Escalon <br />County <br />I San Joaquin <br />EMD <br />Zip Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />BZ Service Station Maintenance <br />Phone <br />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 />Rick Smith <br />ICC Number <br />9940359 <br />ICC Expiration Date <br />11/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer & Test Equipment Training Certifications <br />Expiration Date <br />VR TLS - C30045 <br />4/15/2023 <br />VMI LD - 4928 <br />4/27/2023 <br />4. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br />l 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 <br />Date <br />7/20/2021 <br />Total # of Pages <br />CERS= California Environmental Reporting System, GPH= Gallons Per Hour, ID= Identification, 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 />