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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 /> 1118123 <br /> Facility Name <br /> KWIK SERV LODI BW113 <br /> Facility Address City ZIP Code <br /> 420 W KETTLEMAN LANE LODI , 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> LC SERVICES (559) 444-1730 <br /> Mailing Address <br /> 3887 N VALENTINE AVE, FRESNO, CA 93722 <br /> Service Technician Performing Test <br /> I CHARLES SHRABEL <br /> Contractor/Tank Tester License Number <br /> 1799267 <br /> ICC Number ICC Exp37 <br /> iration Date <br /> i 9477557 _ 7/17124 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VR #C28984 10/24 <br /> VMI #4775 1 D/24 <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, 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 /> ae�i1`2/,� <br /> l :ERS = 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/PressLire/Hvdrestatic <br />