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Appendix VI <br /> Underground Stra a Tank <br /> Monitoring i iC ti n Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 2/3/25 <br /> Facility Name <br /> MANTECA CHEVRON <br /> Facility Address City ZIP Code <br /> 1257 W YOSEMITE MANTECA 95337 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> FRANZEN HILL (559) 688-2977 <br /> Mailing Address <br /> 1100 N J STREET <br /> Service Technician Performing Test <br /> CHALS SHRABEL <br /> Contractor/Tank Tester License Number <br /> 304147 <br /> ICC Number ICC Expiration Date <br /> 9477557 6/23/26 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VR #C28984 9-30-26 <br /> VMI #4778 8-11-26 <br /> 1 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> l 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 /> 2/3125 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 /> Pagel of 6 <br />