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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYRE OF ACTION LJ Installation �=J Repair Q 12 Morph <br />1. FACILITY INFORMATION <br />CERS ID <br />10165883 <br />Certification Date <br />12/23/2020 <br />Facilit�r Name <br />7-EI#20632, MKT 2368 <br />Facility Address <br />4627 DA NCI DR @ MARCH LN <br />C%TON <br />STO KTON <br />ZIP Code <br />95207 <br />2. SERVICE TECHNICIAN INFORMATION <br />ComanX Performing the Certification <br />Tanknol gy, In <br />Phone <br />800-964-1250 <br />Mailin�q Address <br />11000 N opac Expy #500 Austin, Tx 78759 <br />TRepvic. Technician Performing Test <br />im lebec <br />Contractor/Tank Tester License Number <br />Class A General Engineering 743160 <br />IGC Number <br />8001435 <br />ICC Expiration Date <br />06/17/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW:EVR Phase 1 <br />01/01/2022 <br />ICC:CA UST Service Technician <br />06/17/2021 <br />VMI:TLDT-5000 Tester <br />07/14/2022 <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 76, section 2638; that required supporting <br />documentation is attached; and all information contained herein is accurate. <br />Service Technician Signature <br />Date <br />12/23/2020 <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, UDG = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = VacuumlPressurelHydrostatic <br />Page 1 of 6 <br />