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Appendix Vi <br /> Underground Storage Tank <br /> Monitoring tem Cerfification Form <br /> TYPE OF ACTION Ll Installation Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10180661 _ 10712312025 <br /> F=adlity Name <br /> One Stop !Market <br /> Facility Address City ZIP Code <br /> 1151 W. Louise Ave Manteca 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite IV Contractors (209) 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton, CA. <br /> Service Technician Performing Test <br /> Ernesto Esqueda <br /> Contractor/Tank Tester License Number <br /> 11001331 <br /> ICC Number ICC Expiration Date <br /> 10399647 031/912027 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root C3659 041121202E <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> l hereby certify that the monitoring system Is operational in accordance with California Cade <br /> of Regulations, ,lute 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 /> 07/2312025 6 <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hors, Ib = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector. NA = Not Applicable, SW= ingle- <br /> 1 ailed, UDC = U nd er-D isperise r Containment, UST = Underground Storage Tare . <br /> PH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />