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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation F1 Functionality ❑ Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181359 _ _ _ 11/21/2022 <br /> Facility Name <br /> Gavinko Gas & Food <br /> Facility Address j City County Zip Code <br /> 7700 Moreland Dr Stockton_ 1 San Joaquin EMD <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> BZ Service_Station_Maintenance 916-371-238.0 <br /> Mailing Address <br /> 1041 Triangle Ct, West Sacramento, CA 95805 <br /> rContractor/Tank Tester License Number <br /> 1433159 _ <br /> Service Technician Performing Test ICC Number ICC Expiration Date <br /> Jeff Raven 9326216 7/24/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> VR TLS - C26124 2/3/2024 <br /> VMI LD -4596 1/20/2024 <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 /> is attached;and a#infer a ion contained herein is accurate. <br /> Se i T hni Signature Date Total # of Pages <br /> 11/21/2022 <br /> CE VCalifornia Environmental Reporting System, GPFI- Gallons Per Hour, ID= identification, ICC= <br /> Int onal 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 7 <br />