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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 /> 10180561 12/26/2023 <br /> Facility Name <br /> ESCALON MINI MART <br /> Facility Address City ZIP Code <br /> 1097 YOSEMITE AVE ESCALON 95320 <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 /> Edward Stearns <br /> Contractor/Tank Tester License Number <br /> CSLB: 958763 Lic # 14-1760 <br /> ICC Number ICC Expiration Date <br /> 8883080-UT 11/05/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root A31048 7/31/25 <br /> I ncon 1009893708 11/26/2024 <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 Date Total # of Pages <br /> (9-4* d Qb 12/26/2023 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 />