Laserfiche WebLink
Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION 0 Installation ® Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10180955 06/20/2024 <br /> Facility Name <br /> Express Fuel and Mart <br /> Facility Address City ZIP Code <br /> 701 E. Charter Way Stockton 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite IV Contractors (209)-461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton, CA. <br /> Service Technician Performing Test <br /> Benjamin Malaspina <br /> Contractor/Tank Tester License Number <br /> 1001331 <br /> ICC Number ICC Expiration Date <br /> 9519380 06104/2026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root Tech C27440 10/17/2024 <br /> 4. CERTIFICATION 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 Date Total # of Pages <br /> 06/20/2024 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 /> Pagel of 6 <br />