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RECEIVED <br /> .Appendix VI 5/17/2022 <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 Certification Date <br /> 10186885 11 /30/2021 <br /> Facility Name <br /> March Lane 76 <br /> Facility Address City County Zip Code <br /> 1916 March Lane Stockton San Joaquin EMD <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> BZ Service Station Maintenance 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 /> Jeff Raven <br /> ICC Number ICC Expiration Date <br /> 9326216 7/24/2023 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer & Test Equipment Training Certifications Expiration Date <br /> VR TLS - C26124 1 /22/2022 <br /> VMI LD - 4596 2/3/2022 <br /> 4 . CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> / 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 attac ed; and al/ information contained herein is accurate. <br /> Se c echnicloan Signature Date Total # of Pages <br /> 11 /30/2021 <br /> CE California Environmental Reporting System , GPI-1 = Gallons Per Hour , ID = Identification , ICC = <br /> In national 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 />