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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYRE OF ACTION ® Installation �=J Repair a 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 06/18/2021 <br /> Facility Name <br /> 7-ELEVEIq 41216 <br /> Facility Address City ZIP Code <br /> 770 W.Charter Way Stockton 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> ComanX Performing the Certification Phone <br /> Tanknol gy,In 800-964-1250 <br /> Malllnq Address <br /> 11000 N opac Expy#500 Austin,Tx 78759 <br /> intCerv�ce Technician Performing Test <br /> C Fu rman <br /> Contractor/Tank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number IGC Expiration Date <br /> 9160945 05/03/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root:ATG Technician 04/21/2023 <br /> VMI:TLDT5000 Tester 05/02/2023 <br /> Tanknology Certification:Level III LDT-5000 FTA Certification Exam 02/04/2022 <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 76, section 2638;that required supporting <br /> documentation is attached;and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 06/18/2021 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, SW= Single- <br /> Walled, UDG = Under-Dispenser Containment. UST= Underground Storage Tank, <br /> VPH =VacuumlPressurelHydrostatic <br /> Page 1 of 6 <br />