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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />❑✓ 12 Month <br />1. FACILITY INFORMATION <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 = <br />CERS ID <br />10180839 <br />Certification Date <br />7/3/2024 <br />Facility Name <br />STOCKTON FOOD & GAS <br />Facility Address <br />1605 S. EL DORADO STREET <br />City <br />STOCKTON <br />ZIP Code <br />95206 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />ECO CHEK <br />Phone <br />800-555-2435 <br />Mailing Address <br />PO BOX 1394 Lafayette CA <br />Service Technician Performing Test <br />Edward Stearns <br />Contractor/Tank Tester License Number <br />14-1760 Ex. 9/30/25 <br />ICC Number <br />8883080 -UT <br />ICC Expiration Date <br />11/5/2024 <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 />3/1/25 <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 <br />(9.�ard 03te <br />Date <br />7/3/2024 <br />Total # of Pages <br />6 <br />Walled, UDC UDC = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />