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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 0 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10180567 05-02-2024 <br /> Facility Name <br /> EMILS LIQUOR AND SPORTS SHOP <br /> Facility Address City ZIP Code <br /> 1405 CAILFORNIA STREET ESCALON 95320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> ECO CHEK COMPLIANCE INC. 888-500-CHEK <br /> Mailing Address <br /> P.O. BOX 1394 LAFAYETTE CA 94549 <br /> Service Technician Performing Test <br /> Felix Ramirez <br /> Contractor/Tank Tester License Number <br /> 08-1740 Ex.3/31/26 <br /> ICC Number ICC Expiration Date <br /> 8883072-UT 11-11-2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root B34976 07-05-2026 <br /> Incon 1009883708 12/11/2024 <br /> VM 1 2517 11-05-2025 <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 /> Feh;%v R ' 05-02-2024 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 />