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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 /> 10181511 _ _ 7111/24 <br /> Facility Name <br /> H&M Market <br /> Facility Address City ZIP Code <br /> 2501 Jackson Escalon 95320 <br /> [�2.:_SERVICE TECHNICIAN INFORMATION <br /> Company Performing the.Certification Phone <br /> L.C. Services 559-444-1730 <br /> Mailing Address _. <br /> 3887 N. Valentine <br /> Service Technician Performing Test <br /> Mark Steinhauer <br /> Contractor/Tank Tester License Number <br /> 779267 <br /> ICC Number ICC Expiration Date <br /> 8357758 2I11/25 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS Phase I EVR #1002993709 6/17/2025 <br /> Veeder Root TLS-3XX Technician #1347431 3/24/2026 <br /> Red Jacket Leak Detectors #1347431 3/24/2026 <br /> OPW Phase 1 EVR #0148614 6116/2026 <br /> VMI Leak Detector Tester #3988 1/27/2025 <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 TechnirW' Iure Date Total # of Pages <br /> " 7/11/2025 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 /> Wailed, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacutjm1PrPssure/HVdMSt2tic <br />