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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 /> 10876678 08/04/25 <br /> Facility Name <br /> 7 Eleven 41216 <br /> Facility Address City ZIP Code <br /> 770 W Charter Way Stockton 95206 <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 /> Brandon Osby <br /> Contractor/Tank Tester License Number <br /> 485184 <br /> ICC Number ICC Expiration Date <br /> 8898741 1/16/27 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root# C24136 2/14/27 <br /> Franklin Fueling # 1016083710 5/2/26 <br /> Vaporless# 4295 5/5/26 <br /> Vaporless (MLLD)# 4294 5/5126 <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 ja�/�. Date Total # of Pages <br /> � <br /> �/• " l/ 08/04/25 5 <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 />