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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION Ll Installation Ll Repair M 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10165777 09/21/2023 <br /> Facility Name <br /> 7-ELEVEN 14113, MKT 2368 <br /> Facility Address City ZIP Code <br /> 3040 BENJAMIN HOLT DR @ GRIGSBY STOCKTON 95219 <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 /> Clint Fuhrman <br /> Contractor/Tank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number ICC Expiration Date <br /> 9160945 04/14/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications I-Expiration Date <br /> Veeder Root:ATG Technician (C26533) 04/06/2025 <br /> VMI:TLDT-5000 Tester(4463) 04/07/2025 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> J 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 aR information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 09/21/2023 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 />