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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> i <br /> nPE OF ACTION ❑ Installation ❑ Repair X 12 Month <br /> FACILITY INFORMATION <br /> CER;, ID Certification Date <br /> 1/11/2024 <br /> Facility Name <br /> KWIK SERV LODI BW113 <br /> Facility Address City <br /> 420 W KETTLEMAN LANE. ZIP Code <br /> LOCI 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification <br /> ` LC SERVICES Phone <br /> Mailing Address (559) 444-1730 <br /> 3887 N VALENTINE AVE, IFRESNO, CA 93722 <br /> Service Technician Performing Test <br /> 9ryGF �� Andrew Shaffer <br /> Contractor/Tank Tester License Number <br /> 779267 <br /> ICC Number ICC Expiration Date <br /> 10032262 <br /> 109/11125 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Ciao VR #C31141 02/24 <br /> VMI #5204 07/24 <br /> dyi <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> l 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 /> 1/11/2024 <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- 1 <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />