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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION R1 Installation _i Repair Cy 12 Montt <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Dafe <br /> 05/25/2021 <br /> Facility Name <br /> 7-ELEVEN 41216 <br /> Facility Address City ZIP Gode <br /> 770 W.Charter Way Stockton 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N opac Expy#500 Austin,Tx 78759 <br /> Service Technician Performing Test <br /> Brent Bowen <br /> Contractor/Tank Tester License dumber <br /> Class A General Engineering 743160 <br /> ICG Number ICC Expiration Date <br /> 8211862 06/17/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root:VR Level 4 04/23/2023 <br /> ICC:CA UST Service Technician 06/17/2021 <br /> ICC:ICC UST Tank Tightness Testing 06/17/2021 <br /> Tanknology Certification:Level III LDT-5000 FTA Certification Exam 10/02/2022 <br /> OPW:EVR Phase 1 01/05/2022 <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 96,section 2636; that required supporting <br /> documentation is attached;and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 05/25/2021 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, SUV= Single- <br /> Walled, UDC = Under-Dispenser Containment, UST= Underground Storage Tank, <br /> VPH =VacuumlPressureiHydrostatic <br /> Page 1 of 6 <br />