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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 />10181399 05/26/2021 <br />Facility Name <br />GRANTLINE SHELL <br />Facility Address City ZIP Code <br />2375 W GRANT LINE TRACY 95376 <br />FISERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Service Station Systems, Inc. (408) 971-2445 <br />Mailing Address <br />680 Quinn Ave. San Jose, CA 95112 <br />Service Technician Performing Test <br />Samantha McMahan <br />Contractor/Tank Tester License Number <br />485184 <br />ICC Number <br />8950093 <br />ICC Expiration Date <br />09/18/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root TLS - 3XX # B48270 <br />07/23/2021 <br />Vaporless Manufacturing Inc # 4469/4470 <br />06/11/2021 <br />Red Jacket # B48270 <br />08/28/2021 <br />Franklin Fueling Site Safety # 1029453710 <br />10/26/2021 <br />FE Petro # 1029453710 <br />08/30/2021 <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 />Total # of Pages <br />7 <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 />