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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 /> 1130124 <br /> Facility Name <br /> RIPON SHELL <br /> Facility Address City ZIP Code <br /> 710 JACK TONE RD RIPON <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> LC SERVICES 559-444-1730 <br /> Mailing Address <br /> 3887 N VALENTINE <br /> Service Technician Performing Test <br /> JESUS ALVAREZ <br /> Contractor/Tank Tester License Number <br /> 779267 <br /> ICC Number ICC Expiration Date <br /> 9153991 4125 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VR #C26949 7/5/25 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I 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 /> SeE= California <br /> h ician Signature Date Total # of Pages <br /> �jb 2 <br /> 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 />