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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 012 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181209 07/05/2023 <br /> Facility Name <br /> Diamond Gas and Food Mart <br /> Facility Address City ZIP Code <br /> 515 W 11th St. Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Tank-Tight Systems, Inc. 916 378-4167 <br /> Mailing Address <br /> 1729 Crystal Ct. Olivehurst CA 95961 <br /> Service Technician Performing Test <br /> Brian Roth Sr. <br /> Contractor/Tank Tester License Number <br /> 1066914 A HAZ <br /> ICC Number ICC Expiration Date <br /> 8834817 11/15/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Va orless Mechanical Line Leak Detector#4186/4187 10/23/2023 <br /> Veeder Root& Red Jacket#A29945 10/24/2023 <br /> Franklin Fueling Systems# 1035133709 10/24/2023 <br /> API #WS-d244340 06/22/2024 <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 /> 07/05/2023 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 />