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Appendix 111 <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 9 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 110933741 19111125 <br /> Facility Marne <br /> Orlandos Market <br /> r <br /> lity P�ddres pity QIP Dode <br /> 6 Jackson+ AVe Escalor� 95320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> rCompany Performing the Certification Pirrone <br /> etroleum Ser�rice 816=3753 <br /> Mailing Address <br /> 3095 Asante Lane, Vest Sacramento Ca 95591 <br /> Service Technician Performing Test <br /> John PuumalaE <br /> ontractorrfank Tester License Number <br /> 11'1471 <br /> IDD plumber ICC Expiration Date <br /> 5292406 212126 <br /> 3. TRAINING AND CERTIFICATIONS _ <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Vader Root 7126 <br /> VMI 1 t 6 <br /> 4. CERTIFICAT10N BY SERVICE TECHNICIAN CONDUCTING TEST <br /> ! hereby certify that the monitoring system is operational in accordance with allfomra 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 Pages <br /> C RS = California Environmental Reporting System, OPH = Gallons Per Hous', ID = Identification. <br /> ICC = IntemationaI God Counoil, LLD = Line Leek Detector, NA = blot App}icable, SW = S ingle- <br /> 1alled, LIDO = Linder-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = acuumlPressure/Hydrostatic <br /> Page I of 6 <br />