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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 />10180657 <br />Certification Date <br />5/29/2024 <br />Facility Name <br />SYNERGY <br />Facility Address <br />642 N. HUNTER STREET <br />City <br />STOCKTON <br />ZIP Code <br />95202 <br />F2.SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />ECO CHEK <br />Phone <br />209-744-0112 <br />Mailing Address <br />PO BOX 1394 Lafayette CA <br />Service Technician Performing Test <br />Edward Stearns <br />Contractor/Tank Tester License Number <br />CSLB: 958763 Lic # 14-1760 <br />ICC Number <br />8883080 -UT <br />ICC Expiration Date <br />11/05/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root A31048 <br />7/29/2025 <br />Incon 1009893708 <br />11/26/2024 <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 <br />(9_.t*, and 03& <br />Date <br />5/29/2024 <br />Total # of Pages <br />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 />