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Appendix 111 <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION E] Installation E] Repair r[7112 Month <br /> 1. FACILITY INFORMATION <br /> GERS ID Certification Date <br /> 10180551 - San Joaquin EMD 61251 025 <br /> Facility Name <br /> Chevron <br /> Facility Address city ZIP Code <br /> 444 Mossdale Rd Lathrop 95330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> BZ Service Station Maintenance, Inc 916.371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, W Sacramento, DA 95805 <br /> Service Technician Performing Test <br /> Steve Miller 11 <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> IGC Number ICC Expiration Date <br /> 10323143 211212025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment TraiWng Certifications Expiration Date <br /> VR TLS - C34532 121612025 <br /> VMI LD - 5525 1/101202 <br /> 4. CERTIFICATION SYSERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitodng 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 aH information contained herein rs accurate. <br /> Service Technician Signatwe ---- — Date Total # of Pages <br /> /25/2025 <br /> EFTS = California Environmental Reporting System., GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SVV = Single- <br /> Walled, UDC = Under-Dispenser Containment, LIST = Underground Storage Tank. <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page I of <br />