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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYRE OF ACTION LJ Installation �=J Repair Q 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 1018233 01/15/2021 <br /> Facility Name <br /> CHEVRON208118 N-4087-1-3 <br /> FacilU Address C%TON 21P Code <br /> 3355 E.H MMER LANE @ HOLMAN RD STO KTON 95212 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> ComanX Performing the Certification Phone <br /> Tanknol gy,In 800-964-1250 <br /> Mailin�q Address <br /> 11000 N opac Expy#500 Austin,Tx 78759 <br /> SerXOwenice Technician Performing Test <br /> Brent <br /> Contractor/Tank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number ICC Expiration Date <br /> 8211862 06/17/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC:CA UST Service Technician 06/17/2021 <br /> Veeder Root:VR Level 4 04/25/2021 <br /> OPW:EVR Phase 1 01/05/2022 <br /> Tanknology Certification:Level III LDT-5000 FTA Certification Exam 10/02/2022 <br /> ICC:Vapor Recovery System Testing&Repair 10/27/2022 <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 76, 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 /> 0X— 01/15/2021 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, UDG = Under-Dispenser Containment. UST= Underground Storage Tank, <br /> VPH =VacuumlPressurelHydrostatic <br /> Page 1 of 6 <br />