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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Foran <br /> TYPE OF ACTION ❑ Installation ❑ Repair R'12 Month <br /> 1. FAMM 1NFCKfthT1ION <br /> CERS ID Certification Date <br /> 1003 It Ir-'t•,2-0 <br /> Facility Name "O'H o <br /> t� <br /> Facility Address City ZIP Code <br /> ,43`f q 6 <br /> 2, sERv#CIE 11woRNa►T11ON <br /> Company Pefform ng the Certification Phone <br /> Ta.k.�KIb <br /> Mailing Address <br /> �s ��a .�,sfi✓� -fix <br /> Service Technician Performi Test <br /> J tsuS T SaXwy- <br /> Contractorfrank T9ster License Number <br /> eral �neeri 4340 <br /> ICC Number ICC Expiration Date <br /> -T <br /> 3. TRABONG CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> L•evZl LSC -r�txx� �-. � (s�� ( •��• �Z <br /> F-\Jg Yk 1, S s oo�z8 '10 ZZ <br /> 4L tamiN4CATKNSYSERVCETECHNKUNCONDUCTMTM <br /> I hereby certify the monitoring system is operational in accordance with California Code <br /> of Regulations, , division 3, chapter 16, section 26.38; that required supporting <br /> docu and aH information contained herein is accurate. <br /> Service Techn na Date Total#of Pages <br /> "2,o S <br /> CERS = Cavironmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = 1-1 omia 1 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 />