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Appendix VI <br /> Undergrond Storage Tank <br /> Monitoring Sys;m Certification Form <br /> TYPE OF ACTION ❑ Installation ® Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> Facility Name <br /> Facility Address City 4P Code <br /> 19LL-H E vs C-4 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification r Phone <br /> I " [L — T � <br /> Mailing Address <br /> Service Technician Performing Test <br /> Contractor/Tank Tester License Number yy <br /> I <br /> ICC Number ICC Expiration Date <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> r <br /> ZZ-V <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitoring system is operational in accordance with California Code <br /> of Regulations, title 23, division 3, chapterj16, section 2638; that required supporting <br /> documentation is attached; and all inform tion contained herein is accurate. <br /> Service Technician Signa Date Total # of Pages <br /> CERS = California Enironmental Reporting S stem, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line eak 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 />