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Appendix VI <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 /> 10186995 11/28/2022 <br /> Facility Name <br /> March Lane 76 <br /> Facility Address City County Zip Code <br /> 1916 March Lane Stockton San Joa uin 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 ICC Number ICC Expiration Date <br /> Jeff Raven 9326216 7/24/2023 <br /> Service Technician Performing Test ICC Number ICC Expiration Date <br /> Jeramy Cummins 8019661 8/19/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> JR: VR TLS - C26124 2/3/2024 <br /> JR: VMI LD -4596 1/20/2024 <br /> JC: VR TLS - B36375 12/23/2023 <br /> JC: VMI LD - 2270 8/19/2024 <br /> 4. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> l 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 /> ytted;and a#/nfor ®tion contained herein is accurate. <br /> Technicia gnat DateTotal # of Pages <br /> 1/23/2023 <br /> California Environmental Reporting System, GPH= Gallons Per Hour, ID= Identification, ICC= <br /> Inal Code Council, LL <br /> Leak Line Detector, NA= Not Applicable, SW= Single Walled, <br /> UDC= Under Dispenser Containment, UST= Underground Storage Tank, VPN= <br /> Vacuum/Pressure/Hydrostatic <br /> Page 1 of 8 <br />