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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION [ Installation Repair [ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />10063345 7/8/2024 <br />Facility Name <br />819463 Fast Lane <br />Facility Address City ZIP Code <br />116 E Roth Rd Lathrop 95330 <br />[2, SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />IEC Services <br />Phone <br />(916) 993-6312 <br />Mailing Address <br />4901 Warehouse Way, Sacramento, CA 95826 <br />Service Technician Performing Test <br />Alex Warren <br />Contractor/Tank Tester License Number <br />1064168 <br />ICC Number <br />9893393 <br />ICC Expiration Date <br />12/21/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-root Tech C29246 <br />10-14-2024 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />1 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 <br />dv?q <br />Date <br />7/8/2024 <br />Total # of Pages <br />5 <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 />