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Appendix V1 <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION n Installation M Repair 12 Month <br /> 1. FAC ILrTY INFORMATION <br /> CERS ID ertificatlon Date <br /> 10911469 - San Joaquin EMD 19110)2025 <br /> Facility Name <br /> Crrappa Market Shell _ <br /> Facility Address T city ZIP Code <br /> 704 N Jacktone Rd Ripon 95633 <br /> 2. SERVICE TECHNICIAN INFORMATION .� <br /> Company Performing the DerliFication Phone <br /> B Service Station Maintenance, lnc916.371-2388 <br /> Mailing Address - <br /> 1841 Triangle Ct, W Sacramento, CA 95805 <br /> Service Technician Performing Test <br /> Steven Miller 11 -- <br /> Gontractor/Ta nk Tester License Number -- <br /> 433159 <br /> lD Number~ - -- - ------- .�_--- - - - - ICC Expiration Date <br /> 'F 323'I 3 -- .. <br /> 211212026 <br /> 3. TRAIN ING N13 CERTIIFICATIONS <br /> Manufacturer and Test Egw0ment Training Certifications Expiration Date <br /> VR TLS - C34532 121612025 <br /> VMI LD - 5525 111{1)2026 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCT114G 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 Page <br /> 4-1 <br /> CERS = California Environmental Repor6ncg System, GPH = Gallons Per Hour, ID = identification. <br /> I`CC = International Code Council. LLD = Line Leak Detector, NA = Not Applicable, SW = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = VacuumlPressureiHydrostalic <br /> Page 1 of 6 <br />