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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑Installation ❑Repair ❑,/ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181229 01/17/2023 <br /> Facility Name <br /> Speedway 4873 <br /> Facility Address City ZIP Code <br /> 35 N Cherokee Ln Lodi 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Service Station Systems, Inc. (408)971-2445 <br /> Mailing Address <br /> 680 Quinn Ave. San Jose, CA 95112 <br /> Service Technician Performing Test <br /> Kristopher Bell <br /> Contractor/Tank Tester License Number <br /> 485184 <br /> ICC Number ICC Expiration Date <br /> 8833000 07/22/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root TLS-3XX#B33709 03/05/2023 <br /> Vaporless Manufacturing Inc#1324/3225 08/17/2024 <br /> Red Jacket#B33709 05/26/2024 <br /> Franklin Fueling Site Safety#1004933708 06/29/2023 <br /> FE Petro#1004933708 06/20/2024 <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 ��;L4�V4 Date Total # of Pages <br /> 01/17/2023 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 />