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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation ❑ Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />10314517 6/24/2025 <br />Facility Name <br />VAN DE POL - PAC PRIDE <br />Facility Address City ZIP Code <br />351 N. BECKMAN LODI 94544 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />ECO-CHEK Compliance, Inc <br />Phone <br />415-399-9602 <br />Mailing Address <br />P.O. BOX 1394, Lafayette, CA 94549 <br />Service Technician Performing Test <br />Edward Stearns <br />Contractor/Tank Tester License Number <br />CSLB: 958763 Lic # 14-1760 <br />ICC Number <br />8883080 -UT <br />ICC Expiration Date <br />11/06/2026 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root A31048 <br />7/29/2025 <br />Incon 1009893708 <br />11/26/2026 <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 <br />(94*j=j 03&ws <br />Date <br />6/24/2025 <br />Total # of Pages <br />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 />