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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION Ll Installation L] Repair M 12 Month <br />� 1. FACILITY INFORMATION <br />CERS ID <br />Certification Date <br />10182331 <br />01/27/2022 <br />Facility Name <br />CHEVRON 208118 N-4087-1-3 <br />Facility Address City ZIP Code <br />3355 E. HAMMER LANE @ HOLMAN RD STOCKTON 95212 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Tanknology, Inc. 800-964-1250 <br />Mailing Address <br />11000 N Mopac Expy #500 Austin, Tx 78759 <br />Service Technician Performing Test <br />Jesus Saldivar <br />ContractorOTank Tester License Number <br />Class A General Engineering 743160 <br />ICC Number <br />ICC Expiration Date <br />8361393 <br />06/11/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />expiration Date <br />Franklin Fueling: Phil-Tite EVR Ph 1 Systems <br />07/01/2022 <br />Veeder Root:VR Level 4 <br />04/21/2023 <br />ICC:CA UST Service Technician <br />06/11/2023 <br />Tanknology Certification: Level III LDT-5000 FTA Certification Exam 11/07/2024 <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 />01/27/2022 <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 />