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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ANION E] Installation © Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Certification fate <br />10180631 <br />08104{2425 <br />P acility Name <br />{.wick Stop# 152 <br />Facility Address <br />City <br />ZIP Code <br />1721 S. Cherokee Ian <br />Lodi <br />195240 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Phone <br />Elite IV Contractors <br />_ (209)-461-6337 <br />Mailing Address <br />Service Technician Performing Test <br />Jordan Esqueda <br />Contractor/Tank Tester License Number <br />1001331 <br />ICC Number <br />10611893 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equioment Training Certifications <br />eeder-Root 036682 <br />ICC Expiration Date <br />0712112027 <br />Expiration Date <br />8913012027 <br />14. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST I <br />I hereby certify that that monitoring system is operational in accordance with Califo is Code <br />of Regulations, title 23, division 3, chapter 16, section 2633; that required supporting <br />documentation is attached; and ali information contained herein is accurate. <br />Service Technician Signature Date Total # of Pages <br />Tdr041F?4'A 0810412025 6 <br />DERS = California Environmental Deporting System, GPH = Ga lions Per Hour, ID = Ideritifcration, <br />ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SVV Single - <br />Walled, UDC = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = lfacuumlPraYssurelHydrostatic <br />Page 1 of 6 <br />