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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION X Installation ❑ Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10902574 9-23-22 <br /> Facility Name <br /> Safeway #5816 <br /> Facility Address City ZIP Code <br /> 19533 S Mountain House Parkway Mountain House 95391 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> B&T Service Station Contractors 805-431-2704 <br /> Mailing Address <br /> 630 S. Frontage Rd, Nipomo, CA 93446 <br /> Service Technician Performing Test <br /> Nick Adamitz <br /> Contractor/Tank Tester License Number <br /> 902034 <br /> ICC Number ICC Expiration Date <br /> 8158837 6-16-2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> R A20030 3-6-2023 <br /> VMI 8-3-2024 <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 /> Nick Adamitz 9-23-2022 <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 />