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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 /> 10182137 03/20/24 <br /> Facility Name <br /> RUPI- GEORGES MINI MART CHEVRON <br /> Facility Address City ZIP Code <br /> 18662 HWY 88 LOCKEFORD 95237 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Afforda Test 209-744-0112 <br /> Mailing Address <br /> 416 2nd St Galt CA 95632 <br /> Service Technician Performing Test <br /> David Winkler <br /> Contractor/Tank Tester License Number <br /> 08-1739 Ex. 2/28/26 <br /> ICC Number ICC Expiration Date <br /> 8883059-UT 1/30/26 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root B34975 1/28/26 <br /> Incon 1009853708 12/11/24 <br /> VMI 11 /12/25 <br /> BRAVO 9023 1/19/27 <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 /> w 103/20/24 6 <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 />