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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation ❑ Repair 5_/1 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />10180695 7-1-2025 <br />Facility Name <br />Quik Stop Market #76 <br />Facility Address City ZIP Code <br />1030 S. Olive Avenue Stockton 95215 <br />[2, SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Walton Engineering, Inc. 916-373-1166 <br />Mailing Address <br />P.O. Box 1025, West Sacramento, CA 95691 <br />Service Technician Performing Test <br />Nicholas Janoe <br />Contractor/Tank Tester License Number <br />617238 <br />ICC Number <br />8712764 <br />ICC Expiration Date <br />12-13-2025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root B49017 <br />9-27-2025 <br />Vaporless LDT <br />12-27-2025 <br />Bravo <br />5-03-2027 <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 <br />9a4'_0 <br />Date <br />7-1-2025 <br />Total # of Pages <br />11 <br />to <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 />