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Appendix 5 <br /> Underground Storage Tank <br /> Release Dtec#innqui menit Testing Fplk dorm <br /> TESTING TYPE Installation W R pair Q 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181 41 0211312026 <br /> Facility dame <br /> Parkwood Fccd and Gas _ <br /> Facility Address City ZIP code <br /> 1612 W. Hammer Ln Stockton 95209 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing Testing Phone <br /> Elite 1V Contractors ( 09)-461-6337 <br /> Nailing Address <br /> Mite IV Contractors <br /> Service Technician Performing Testing <br /> Jordnn Esgueda _ <br /> Contractor License Number <br /> 100E 33'1-A <br /> [CC Certification I C Expiration Date <br /> 1061183 07111027 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufactnfer and Test Equipment Training Certifications Training Expiration Date <br /> eeder-Root ATG 06682 0913012027 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that all equipment identified in this form has been tested in accordance with <br /> Caflfornia Code of Regulations, title 23, division 3k chapter 16, section 2663, that required <br /> supporting documentation is attached; and all information contained herein is accurate. <br /> Service Technician Signature Date Total ## of Pages <br /> _TA_ T�� 10211312026 6 <br /> C E R 5 = 0 alifornia Environmental Reporting System, G PH = Gallons Per Hour, ID = Identification. <br /> I C C = International Dade Council, LLD = Line Leak Detector, NA = Not A4ppticable, UDC = Under- <br /> Dispenser Containment, UST= Underground Storage Tank. VPH = Vacnum1PreasurelHydrostatic <br /> Page 1 of 6 <br />