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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 03121/2023 <br /> Facility Name <br /> CALIFORNIA STOP <br /> Facility Address City ZIP Code <br /> 2224 S MANTHEY ROAD STOCKTON, CA 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> I MB SERVICES 707-4393778 <br /> Mailing Address <br /> PO BOX 1299 SUISUN CITY, CA 94520 <br /> Service Technician Performing Test <br /> Rudy Melendez <br /> Contractor/Tank Tester License Number <br /> ; 945643 <br /> ICC Number ICC Expiration Date <br /> 9036538 02/25/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VR C23738 04/10/2023 <br /> I <br /> LDT-890 #4367 04/27/2024 <br /> MLD #2884 04/27/2024 <br /> I <br /> 14. 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 16, section 2638; that required supporting <br /> documentation is attached; and all information contained herein is accurate. �I <br /> Service Technician Signature Date Total # of Pages <br /> 03121/2023 6 <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 />