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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ® Installation ❑f Repair 12 Month <br />1. FACILITY INFORMATION <br />CERS 1D _ - Certification Daae <br />10844113 - Sart Joaquin EMD 711712025 <br />Facility dame <br />Power Pump Plaza <br />Facility Address City ZIP Code <br />141 E Harney Lane Lodi 195240 <br />3. SERVICE TECHNICIAN INFORMATION <br />ompany Performing the Certification Phone <br />BC - Service Station Maintenance, Inc 91"71-2380 <br />Mailing Address <br />1041 Triangle Ct, W Sacramento, CA 95805 <br />Service Technician Perform Gng Test <br />Randy Wilkerson <br />Dontractorrrank Tester License Number <br />433159 <br />ICC Number <br />8822039 <br />3. TRAI NIII G AN C} C ERTtFI ATIONS <br />Manufacturer and Test Equipment Training Certifications <br />R TLS - C36297 <br />VMI LD - 4576 <br />I CCC Expiration Date <br />i 1212712025 <br />Expiration Date <br />412812027 <br />1 211 312 925 <br />4. CERTIFICATION BY SERVICE TE HNI IAN CONDUCTING TEST <br />1 hereby certify that the monitoring system 1s operationai in accordance with Catifomia Code <br />of Regulations, title 23, division 3, chapter 18, section 2838; that required supporting <br />documentation is attached; and all information contained herein is accurate. <br />Service Technician Signature <br />Date Total # of Pages <br />711712025 <br />ERS = California Environmental Reporting System. GPH = Gallons Per Flour, ID = Identification, <br />ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable. SW= Single - <br />Walled. UDC =iander-Dispenser Containment, UST = Underground Storage Tank, <br />VPH = Vacuum PressurelHydrostatic <br />Page 1 of <br />