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Appendix V1 <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation D Repair 9 12 Month <br />1. FACILITY INFORMATION <br />EfS ID <br />10182295 <br />Certification Dateu <br />7M6125 <br />Facility Name <br />rlandos Market <br />Facility Address city <br />18754 Hwy 26 Linden <br />2. SERVICE TECHNICIAN INFORMATION <br />ZIP Code <br />195236 <br />company Performing the Certification <br />JP Petroleum Service <br />Phone <br />1916-372-5693 <br />Mailing Address <br />306 5 Asante Lane, West Sacramento Ca 95551 <br />Service Technician Performing Test <br />Gabe Garcia <br />Contractor/Tank Tester License Number <br />$11471 <br />ICC Number <br />8413928 <br />; ICC Expiration Date <br />j 1012026 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certificadons <br />Expiration Date <br />e€ter Root <br />7126 <br />VAI <br />12/26 <br />J <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, tale 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 f f Total` of Pages <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 = 8 ing le- <br />Wa I led, U DC = Under -Dispenser Containment. UST= Underground Storage Tank, <br />VPH = Vacuum lPressure/Hydrostatic <br />Page 1 of <br />