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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Farm <br /> TYPE OF ACTION ❑ Installation ❑ Functionality ® Repair E 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 1/8/2021 <br /> Facility Name <br /> Kwik Sery Lodi <br /> Facility Address City County Zip Code <br /> 420 W Kettleman Lane Lodi San Joa ui ENV <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> BZ Service Station Maintenance 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, West Sacramento, CA 95805 <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> Service Technician Performing Test <br /> Jeff Raven and Jeramy Cummins <br /> ICC Number ICC Expiration Date <br /> 9326216 - 8/31/2021 and 8019661 - 9/17/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer 8 Test Equipment Training Certifications Expiration Date <br /> VR TLS - C26124 - 1/22/2022 and B36375 - 1/20/2022 <br /> VMI LD - 4596 - 2/3/2022 and 3370 - 8/27/2022 <br /> 4. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> /hereby certify that the monitoring system is operational in accordance with California Code of <br /> Regulations, Title 23, division 3, chapter 16, section 2638, that required supporting documentation <br /> is attached, and all information contained herein is accurate. <br /> Service i is Lire Date Total # of Pages <br /> CERS= C i rnia Environmental Reporting System, GPH= Gallons Per Hour, ID= Identification, ICC= <br /> Internatio al Code Council, LLD= Leak Line Detector, NA= Not Applicable, SW= Single Walled, <br /> UDC= Under Dispenser Containment, UST= Underground Storage Tank, VPH= <br /> Vacuum/Pressure/Hydrostatic <br /> Page 1 of 9 <br />