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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ry Installation <br /> Repair ® 12 Month <br /> 1. FACILITY INFORMATION Certification Date <br /> CERS ID <br /> 9/10/2025 <br /> 10181335 ___7 <br /> Facility Name <br /> Chevron #94275 ZIP Code <br /> Facility Address City <br /> Stockton 95207 <br /> 2905 W Benjamin Holt Dr <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Phone <br /> Company Performing the Certification Phone <br /> Wayne Perry Inc. <br /> Mailing Address <br /> 8281 Commonwealth Ave. <br /> Service Technician Performing Test <br /> Anthony Almanza <br /> Contractor/Tank Tester License Number <br /> 300345 <br /> ICC Number ICC Expiration Date <br /> 10252363 4/15/2026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> C32244 12/6/2025 <br /> ICC: CA UST Service Technician (10252363) 04/15/2026 <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 Date Total # of Pages <br /> 9/10/2025 2 <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 />