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7 1� Appendix VI <br /> Underground Storage Tank <br /> TYPE OF ACTION Monitoring System Certification Form <br /> ® Installation Repair <br /> 1• FACILITY INFORMATION © 12 Month <br /> CERS ID <br /> 10376026 Certification Date <br /> Facility Name <br /> ta'111 a7 0 <br /> e <br /> Facility Address <br /> City _ ZIP Code <br /> r �G K D try <br /> 2. SERVICE TECHNICIAN CZrZ J <br /> INFORMATION <br /> Company Performing the Certification <br /> Wayne Perry Inc. Phone <br /> Mailing Address 714-826-0352 <br /> 8281 Cpmmonwealth Ave. <br /> Service Technician Performing Test <br /> Glenn Kelley <br /> Contractor/I ank Tester License Number <br /> 300345 <br /> ICC Number ICC Expiration Date <br /> 445493360 <br /> 3/27125 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veederoot B35609 12-27-24 <br /> ffFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> certify that the monitoring system is operational in accordance with California Code <br /> tions, title 23, division 3, chapter 16, section 2638; that required supporting <br /> tation is attached; and all information contained herein is accurate. <br /> Service Technician Signature <br /> Date Total#of Pages <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hlicable, SW S nglen <br /> ICC = International Code Council,Conttainm''ne Leak ent, USTDeUnderglround Storage Tank, <br /> Walled, UDC = Under-DisPedrostatic <br /> VPH = VacuumlPressure/Hy Page 1 of 6 <br />