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Appendix VI <br /> Underground Storage Tank REGE VED <br /> Monitoring System Certification Form OCT 1 "2020 <br /> TYPE OF ACTION ❑ Installation ❑ Repair 8 12 ,� � NMENi:/'� !_ HEALTH <br /> 1 . FACILITY INFORMATION <br /> SPAR a " rNT <br /> CERS ID Certification Date <br /> 10181363 10/7/2020 <br /> Facility Name <br /> CHARTER WAY CHEVRON <br /> Facility Address City ZIP Code <br /> 508 W CHARTER WAY STOCKTON , CA 95206 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> AFFORDA TEST 209 - 744 - 0112 <br /> Mailing Address <br /> 416 2ND STREET GALT , CA 95632 <br /> Service Technician Performing Test <br /> ZANE NIMMO <br /> Contractor/Tank Tester License Number <br /> 04 - 1676 Ex . 3 /31 /22 <br /> ICC Number ICC Expiration Date <br /> 8883064 - UT 6/ 1 /21 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root A28446 10/2 /21 <br /> Incon 1009843708 11 /30 /20 <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 /> 10 /7 /2020 6 <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 /> i <br />