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TYPE OF ACTION <br />Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />❑ Installation ❑ Repair ❑✓ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10180875 <br />Certification Date <br />04/07/21 <br />Facility Name <br />GREWAL'S GAS & LIQUOR <br />Facility Address <br />4100 E FREMONT ST <br />City <br />STOCKTON, CA <br />ZIP Code <br />95215 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />AFFORDA TEST <br />Phone <br />209-744-0112 <br />Mailing Address <br />416 2ND STREET GALT, CA 95632 <br />Service Technician Performing Test <br />DAVID WINKLER <br />Contractor/Tank Tester License Number <br />08-1739 Ex. 3/31/23 <br />ICC Number <br />8883059 -UT <br />ICC Expiration Date <br />1/27/22 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root B34975 <br />2/7/22 <br />Incon 1009853708 <br />12/11/22 <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 16, section 2638; that required supporting <br />documentation is attached, and all information contained herein is accurate. <br />Service Technician Signature <br />w 104/07/21 <br />Date <br />Total # of Pages <br />6 <br />CERS = California Environmental Reporting S) <br />ICC = International Code Council, LLD = Line I <br />Walled, UDC = Under -Dispenser Containment, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Stem, GPH = Gallons Per Hour, ID = Identification, <br />eak Detector, NA = Not Applicable, SW = Single - <br />UST = Underground Storage Tank, <br />Page 1 of 6 <br />