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Appendix VI <br />Undergrownd Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION E1 Installation Repair 0 12 Month <br />9. FACILITY INFORMATION <br />CERS IDCertification <br />Date <br />3Iddjdo,�AI <br />Facility Name <br />Escalon Mini Mart <br />Facility Address <br />1097 E. Yosemite Ave. <br />City <br />Escalon <br />ZIP Code <br />95320 <br />2. SERVICE TECHNICIAN 1NF®RMATI®N <br />Company Performing the Certification <br />Donlee Pump Company <br />Phone <br />(209) 5379396 <br />Mailing Address <br />2825 Railroad Ave. Ceres, CA. 95307 <br />Service Technician Performing Test <br />Jerry Langrell <br />Contractor/Tank Tester License Number <br />ICC Number <br />8899490 <br />ICC Expiration Date <br />7/23/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Incon <br />1/5/2021 <br />Veeder Root <br />11/20/2021 <br />Vaporless <br />8/13/2021 <br />4.` -CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />1 hereby certify that the monitoring system is operational in accordance with California Code <br />of Regulations, title 23, division 3, chapter 96, section 2638; that required supporting <br />documentation is attached, and all information contained herein is accurate. <br />Service Technic' n Si nature <br />b <br />Date <br />i)Ag" <br />Total # of Pages <br />J <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, UDC = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />