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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <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 />TYPE OF ACTION Installation Repair 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />Facility Name <br />Facility Address City ZIP Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Mailing Address <br />Service Technician Performing Test <br />Contractor/Tank Tester License Number <br />ICC Number ICC Expiration Date <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <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 /> <br />116 Roth Road Lathrop 95330 <br />Nwestco LLC (800) 339-9930 <br />2209 Zeus Court, Bakersfield, CA 93308 <br />VMI #4646 <br />5