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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 Certification Date <br />10166017 6/25/25 <br />Facility Name <br />7 -Eleven 32190 <br />Facility Address City ZIP Code <br />4943 S State Rt 99 Stockton 95215 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Service Station Systems (408) 971-2445 <br />Mailing Address <br />680 Quinn Ave San Jose CA 95112 <br />Service Technician Performing Test <br />Hunter Gustin <br />Contractor/Tank Tester License Number <br />485184 <br />ICC Number <br />9139238 <br />ICC Expiration Date <br />5/28/27 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root # B48601 <br />9/13/25 <br />Franklin Fueling # 1019523709 <br />3/29/26 <br />Vaporless # 5601 <br />3/29/26 <br />Vaporless (MLLD) # 5600 <br />3/29/26 <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 II <br />I 46� <br />Date <br />6/25/25 <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 />