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Appendix VI 00010 <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair D 12 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181541 01105/2023 <br /> Facility Name <br /> Pacific Bell Telephone Co . dba AT&T California <br /> Facility Address City ZIP Code <br /> 1812 Coley Ave . Escalon 95320 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> TAIT Environmental Services , Inc . (714 ) 560- 8222 <br /> Mailing Address <br /> 11280 Trade Center Dr. , Rancho Cordova , CA 95742 <br /> Service Technician Performing Test <br /> Jaime Jauregui <br /> Contractor/Tank Tester License Number <br /> 588098 <br /> ICC Number ICC Expiration Date <br /> 8340695 07-25-2024 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder root - B48138 09-07-2024 <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 /> 01 /05/2023 <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 />