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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 <br />10184829 <br />Certification Date <br />06/21/2021 <br />Facility Name <br />Rancho San Miguel Market <br />Facility Address <br />1427 S Airport Way <br />City <br />Stockton <br />ZIP Code <br />95206 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Service Station Systems, Inc. <br />Phone <br />(408) 971-2445 <br />Mailing Address <br />680 Quinn Ave. San Jose, CA 95112 <br />Service Technician Performing Test <br />Kristopher Bell <br />Contractor/Tank Tester License Number <br />485184 <br />ICC Number <br />8833000 <br />ICC Expiration Date <br />07/28/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root TLS - 3XX # B33709 <br />03/05/2023 <br />Vaporless Manufacturing Inc #1324/3225 <br />11/01/2021 <br />Red Jacket #1333709 <br />06/09/2022 <br />Franklin Fueling Site Safety #1004933708 <br />09/14/2021 <br />FE Petro # 1004933708 <br />07/09/2022 <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 16, section 2638; that required supporting <br />documentation is attached; and all information contained herein is accurate. <br />Service Technician Signature/Q <br />Date <br />06/21/2021 <br />Total # of Pages <br />6 <br />CERS = California Environmental Reporting S <br />ICC = International Code Council, LLD = Line <br />Walled, UDC = Under -Dispenser Containment, <br />VPH = Vacuum/Pressure/Hydrostatic <br />ystem, GPH = Gallons Per Hour, ID = Identification, <br />Leak Detector, NA = Not Applicable, SW = Single - <br />UST = Underground Storage Tank, <br />Page 1 of 6 <br />