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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ® Installation ® Repair [rl 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10118074 <br />Certification Date <br />03/15/2023 <br />Facility Name <br />Circle K <br />Facility Address <br />2575 Country Club <br />City <br />Stockton <br />ZIP Code <br />95204 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Elite IV Contractors (209) 461-6337 <br />Mailing Address <br />2535 Wigwam Dr Stockton CA <br />Service Technician Performing Test <br />Number 1001331 <br />Contractor/Tank Tester License Number <br />Benjamin Malaspina <br />ICC Number <br />9519380 <br />ICC Expiration Date <br />06/1712024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root ATG C27440 <br />10/1712024 <br />VMI 890 Tester 4515 <br />08/3012023 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />1 hereby certify that the monitoring system is operational in accordance with California Code <br />of Regulations, title 23, division 3, chapter 96, section 2638; that required supporting <br />documentation is attached; and all information contained herein is accurate. <br />Se rvi a Technician Signature <br />Date <br />03/15/2023 <br />Total # of Pages <br />6 <br />4s V <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 />