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RECEIVED <br /> Appendix VI <br /> Underground Storage Tank JAN 0 7 2022 <br /> Monitoring System Certification Form <br /> ENVIRONMENTAL <br /> TYPE OF ACTION ❑ Installation ❑ Repair n✓ 12 Month <br /> HEALTH DEPARTMENT <br /> Is FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10767814 04/21 /21 <br /> Facility Name <br /> TOKAY KWIK SERVE Waste Oil <br /> Facility Address City ZIP Code <br /> 420 KETTLEMAN LANE LODI , CA 95240 <br /> 2 SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> AFFORDA TEST 209 - 744 -0112 <br /> Mailing Address <br /> 416 2ND STREET GALT , CA 95632 <br /> Service Technician Performing Test <br /> DAVID WINKLER <br /> Contractor/Tank Tester License Number <br /> 0 & 1739 Ex . 3/31 /23 <br /> ICC Number ICC Expiration Date <br /> 8883059- UT 1 /27/22 <br /> 3 TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root 834975 2 /7/22 <br /> ncon 1009853708 12/ 11 /22 <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 Date Total # of Pages <br /> �.� 04 /21 /21 6 <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 />