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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION © Installation © Repair 0 12 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10180797 8/2 /2021 <br /> Facility Name <br /> Quik Stop Market #39 <br /> Facility Address City ZIP Code <br /> 2285 E fremont st Stockon 95205 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Walton Engineering , Inc . 916 -373 - 1166 <br /> Mailing Address <br /> P . O . Box 1025 , West Sacramento , CA 95691 <br /> Service Technician Performing Test <br /> Maxwell Hines <br /> Contractor/Tank Tester License Number <br /> 617238 <br /> ICC Number ICC Expiration Date <br /> 8750053 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder- Root 3/3/2022 <br /> Vaporless 07/28/2022 <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 Date Total # of Pages <br /> r ' � 8 /2/2021 <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 />