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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Fora <br /> TYPE OF ACTION 0 Installation M Repair T 12 Month <br /> I <br /> 1. :FACILITY INFORMATION <br /> I <br /> CERS ID Certification Date <br /> 12/21/2021 <br /> Facility Name <br /> Escalon Mini Mart <br /> Facility Address City ZIP Code <br /> 1097 E. Yosomite Escalon 96320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Donlee Pump Company (209) 537-9396 <br /> Mailing Address <br /> 2625 Railroad Ave. Ceres, CA. 95307 <br /> Service Technician Performing Test <br /> Mario Romero <br /> Contractor/Tank Tester License Number <br /> 9 <br /> ICC Number ICC Expiration Date <br /> 8034353 10/6/2022 <br /> 3, TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling 1 Incon <br /> 4. CERTIFICATION BY;SERVICE TECHNICIAN CONDUCTING TEST <br /> !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 Date Total # of Pages <br /> CER, = Californi 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 />