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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 <br />10180605 <br />Certification Date <br />05/15/2024 <br />Facility Name <br />Flag City Chevron <br />Facility Address <br />6421 Capitol <br />City <br />Lodi <br />ZIP Code <br />95242 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Elite IV Contractors <br />Phone <br />(209)-461-6337 <br />Mailing Address <br />2535 Wigwam Dr. Stockton, CA. 95205 <br />Service Technician Performing Test <br />Adrian Rodriguez <br />Contractor/Tank Tester License Number <br />1001331 <br />ICC Number <br />9914593 <br />ICC Expiration Date <br />08/10/2024 <br />3. TRAININ1G AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root Installer C29284 <br />11/07/2024 <br />4. CERTIFICATION <br />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 16, section 2638; that required supporting <br />documentation is attached; and all information contained herein is accurate. <br />Service Technician Signature <br />Date <br />05/15/2024 <br />Total # of Pages <br />3 <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 />