Laserfiche WebLink
Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />D 12 Month <br />1. FACILITY INFORMATION <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 = <br />CERS ID <br />10180955 <br />Certification Date <br />6/4/2024 <br />Facility Name <br />EXPRESS FUEL AND MART <br />Facility Address <br />701 E. CHARTER WAY <br />City <br />STOCKTON <br />ZIP Code <br />95206 <br />li.�SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />ECO -CHEK <br />Phone <br />888-500-CHEK <br />Mailing Address <br />3249 MT. DIABLO CT. LAFAYETTE CA <br />94549 <br />Service Technician Performing Test <br />Zane Nimmo <br />Contractor/Tank Tester License Number <br />04-1676 Ex. 4/30/2025 <br />ICC Number <br />8883064 -UT <br />ICC Expiration Date <br />5/27/2025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root A28446 <br />10/9/2025 <br />Incon 1009843708 <br />12/5/2024 <br />V MI 1272 & 2072 <br />2/2/2025 <br />BRAVO <br />1/19/2027 <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 />Date <br />6/4/2024 <br />Total # of Pages <br />6 <br />Walled, UDC UDC = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />