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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION El Installation LJ Repair Q 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181335 02/17/2021 <br /> Facility Name <br /> CHEVRON#94275 <br /> Facility Address Citi ZIP Cade <br /> 2905 W.B NJAMIN HOLT @ 1-5 STO KTON 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Tanknology,In 800-964-1250 <br /> Mailin�q Address <br /> 11000 N opac Expy#500 Austin,Tx 78759 <br /> Service Technician Performing Test <br /> Brent Bowen <br /> ContractorfTank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number ICC Expiration Dat <br /> 8211862 06/17/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration date <br /> Veeder Root:VR Level 4 04/25/2021 <br /> Tanknology Certification:Level III ATG Operability Training Certification Exam 03/25/2023 <br /> ICC:CA UST Service Technician 06/17/2021 <br /> ICC:ICC UST Tank Tightness Testing 06/17/2021 <br /> OPW:EVR Phase 1 01/05/2022 <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 96,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 /> 02/1712021 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 />