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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 4/28/21 <br /> Facility Name <br /> MANTECA CHEVRON <br /> Facility Address City ZIP Code <br /> 1257 W. YOSEMITE AVE MANTECA 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> FRANZEN HILL 559-.688-2977 <br /> Mailing Address <br /> 1100 N. J STREET TULARE CA 93274 <br /> Service Technician Performing Test <br /> DAVID MARTIN <br /> Contractor/Tank Tester License Number <br /> A304147 <br /> ICC Number ICC Expiration Date <br /> 5246124 8-29-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VEEDER ROOT A27289 1/31/2023 <br /> VMI 1905 11/3/2022 <br /> INCON 1022923708 2/13/2023 <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 /> 4/28/21 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 />