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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ® Installation ® Repair M 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Certification Date <br />10484500 - San Joaquin EMD <br />6/5/2025 <br />Facility Name <br />Arco AmPm <br />Facility Address <br />City <br />ZIP Code <br />255 E Harney Lane <br />Lodi <br />95240 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />BZ Service Station Maintenance, Inc 916-371-2380 <br />Mailing Address <br />1041 Triangle Ct, W Sacramento, CA 95805 <br />Service Technician Performing Test <br />Randy Wilkerson <br />Contractor/Tank Tester License Number <br />433159 <br />ICC Number ICC Expiration Date <br />8822029 12/27/2025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />VR TLS - C36297 4/28/2027 <br />VMI LD - 4576 12/13/2025 <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 />6/5/2025 <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 />