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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair p 12 Month <br /> Fi- <br /> . FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181191 01/20/23 <br /> Facility Name <br /> TULARE FARMS <br /> Facility Address City ZIP Code <br /> 2771 E FRENCH CAMP _ FRENCH CAMP 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Afforda Test 1209-744-0112 <br /> Mailing Address <br /> 416 2nd St Galt CA 95632 <br /> Service Technician Performing Test <br /> David Winkler <br /> Contractor/Tank Tester License Number <br /> 08-1739 Ex. 3131123 <br /> ICC Number ICC Expiration Date <br /> 8883059-UT 01/30/24 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root B34975 217124 <br /> Incon 1009853708 12/10/24 <br /> VAPORLESS 2529 11/08/23 <br /> BRAVO 2021-2929023 01/26/24 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> is <br /> !hereby certify that the monitoring systemoperational 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 Technician Signature Date Total #of Pages <br /> 01/20/23 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 />