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Section IX <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID I �g 0/Cert13/2020 fication Date <br /> Facility Name l <br /> Sunwest Chevron <br /> Facility Address City County Zip Code <br /> 2758 W Kettleman Lane Lodi San Joaquin <br /> 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,ICA 95805 <br /> Contractor/Tank Tester License Nurd,ber <br /> 433159 <br /> Service Technician Performing Test <br /> Rob Jacobs <br /> ICC Number ICC Expiration Date <br /> 8819943 6/25/2022 <br /> �3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> VR TLS - C23345 1/16/2021 <br /> VMI LD - uALAD <br /> 4. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> l 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 hef-ein is accufate. <br /> ServiVenici Signature Date t31� Total # of Pages <br /> CERS= California Environmental Reporting System, GPH= Gallons Per Hour, ID= Identification, ICC= <br /> International 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 8 <br /> i <br />