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Appendix A <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION 0 Installation Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> GERS ID Certification Date <br /> 10181383 - San Joaquin EII+ID 11/24/2025 <br /> Facility Name <br /> Goo a Kishida <br /> Facility Address city ZIP Code <br /> 1725 Ackerman Dr Lodi 195240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> SZ Service Station Maintenance, Inc _ 916 71-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, W Sacramento, CA 95805 <br /> Service Technician Performing Test <br /> Rhome Desbiens <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> ICC Number IDC Expiration Date <br /> 8245558 1112012026 <br /> 3. TRAINING AND CERTIFICATIONS -- <br /> Man ufacturerand Test Equipr ent Training Cortificahonrs Expiration Date <br /> Cmntee - RD45167 10 1116/2027 <br /> VMI LD - 2906 2l 31202f <br /> 4. CERTIFICATION EY SEk kDE TECHNICIAN'C0NDUCTINC:TEST <br /> l hereby certify that the monitoring system is operational in accordance with Calil`orr-ra Corte <br /> of Reg ulationas, title 23, division 3, chapter 16, section 2638; that required supporting <br /> documentation Is attached; and all information contained herein is accurate. <br /> ervioe Technician Signature Date Total # of Pages <br /> 1112412025 ID <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council. LLD = r,<ine Leak Detector, NA = Not Applicable, SIN= Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> PH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />