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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 />10181913 02/22/2021 <br />Facility Name <br />Shell <br />Facility Address City ZIP Code <br />16500 S. Harlan Road Lathrop, CA 95330 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />ECO-CHEK Compliance, Inc. <br />Phone <br />888-500-2435 <br />Mailing Address <br />PO Box 1394, Lafayette CA 94549 <br />Service Technician Performing Test <br />Marco Alejos <br />Contractor/Tank Tester License Number <br />958763 A <br />ICC Number <br />8415074 <br />ICC Expiration Date <br />04/27/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root Level 4 #C26930 <br />06/20/2021 <br />FFS 1013893711 <br />07/25/2021 <br />Vaporless LDT 890 #4451 <br />05/10/2021 <br />SBravo #SWAT <br />04/10/2022 <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 16, section 2638; that required supporting <br />documentation is attached; and all information contained herein is accurate. <br />Service Technician Signature <br />Date <br />02/22/2021 <br />Total # of Pages <br />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 />Walled, UDC = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />