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$67758&.6,'( <br />Monitoring System Certification <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 />TYPE OF ACTION ܆܆ Installation ܆ Repair ܆ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />Facility Name <br />Facility Address City ZIP Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Mailing Address <br />Service Technician Performing Test <br />Contractor/Tank Tester License Number <br />ICC Number ICC Expiration Date <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <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 />Service Technician Signature Date Total # of Pages <br />10448341 4/12/2022 <br />LOVES #538 <br />15250 N THORTON RD LODI 95242 <br />Afforda Test 209-744-0112 <br />416 2nd St Galt CA 95632 <br />Edward Stearns <br />14-1760 Ex. 9/30/23 <br />8883080-UT 11/6/2022 <br />Veeder Root A31048 7/31/23 <br />Incon 1009893708 3/1/2023 <br />4/12/2022 6 <br />✔