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Appendix Vi <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION L Installation L Repair 0 12 Montt} <br /> 1, FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10165883 12/15/2021 <br /> FacilitV Name <br /> 7-ELEVEN#20632,MKT 2368 <br /> Facility Address City ZIP Code <br /> 4627 DAV NCI DR @ MARCH LN STOCKTON 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N opac Expy#500 Austin,Tx 78759 <br /> Service Technician Performing Test <br /> Landon Zamora <br /> ContractouTank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC plumber ICC Expiration Date <br /> 9768392 06/08/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certificabons Expiration Date <br /> Veeder Root:ATG Technician 04/27/2023 <br /> PELRP1200 06/05/2079 <br /> Tanknology Certification:Level III LDT-5000 FTA Certification Exam 06/11/2023 <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 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 /> 12/15/2021 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, UDC = Under-Dispenser Containment, UST= Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />