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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION Ll Installation L) Repair _ 12 Month <br /> 1, FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10165815 09/08/2022 <br /> Facility Name <br /> 7-ELEVEN#17334 MKT 2368(N-747) <br /> Facility Address City ZIP Code <br /> 4501 N.PERSHING AVE.@ ROSEMARIE LN. STOCKTON 95207 <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 /> Landon Zamora <br /> Contractor/Tank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number ICC Expiration Date <br /> 9768392 06/08/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root:ATG Technician(C28849) 04/27/2023 <br /> VMI:TLDT-5000 Tester(5126) 03/09/2024 <br /> OPW:EVR Phase 1 (1193608) 02/24/2024 <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 Date Total # of Pages <br /> 09/08/2022 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, SUV = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />