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1 <br /> Appendix VI <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 /> 12/18/2020 <br /> Facility Name <br /> Escalon Mini Mart <br /> Facility Address City ZIP Code <br /> 1097 E . Yosemite Ave . Escalon 195320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Donlee Pump Company (209) 5379396 <br /> Mailing Address <br /> 2825 Railroad Ave . Ceres, CA. 95307 <br /> Service Technician Performing Test <br /> Jerry Langrell <br /> Contractor/Tank Tester License Number <br /> ICC Number ICC Expiration Date <br /> 8899490 7/23/2022 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling / Incon 1 /5/2021 <br /> Veeder Root 11 /20/2021 <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 2638; that required supporting <br /> documentation is attached; and all information contained herein is accurate. <br /> Service Tech i an nature Date Total #f 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 />