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Appendix Vi <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ® Installation 0 Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />rn 12/18/2020 <br />Facility Name <br />Escalon Mini Mart <br />Facility Address <br />City <br />ZIP Code <br />1097 E. Yosemite Ave. <br />Escalon <br />95320 <br />2.SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Donlee Pump Company (209) 537-9396 <br />Mailing Address <br />2825 Railroad Ave. Ceres, CA. 95307 <br />Service Technician Performing Test <br />Jerry Langrell <br />ContractorlTank Tester License Number <br />2 114 - <br />9 <br />_1C <br />ICC Number ICC Expiration Date <br />8899490 7/2312022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling 1 Incon <br />1/5/2021 <br />Veeder Root <br />11/20/2021 <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 Tech i an ' nature <br />Date <br />Total # of Pages <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 />