Laserfiche WebLink
Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑y/ 12 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10184829 06/20/2022 <br /> Facility Name <br /> Rancho San Miguel Market <br /> Facility Address City ZIP Code <br /> 1427 S Airport Way Stockton 95206 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Service Station Systems , Inc . (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 ICC Expiration Date <br /> 8833000 07/28/2022 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root TLS - 3XX # B33709 03/05/2023 <br /> Vaporless Manufacturing Inc #1324/3225 09/23/2022 <br /> Red Jacket # 833709 05/26/2024 <br /> Franklin Fueling Site Safety #1004933708 06/20/2024 <br /> FE Petro # 1004933708 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 Date Total # of Pages <br /> 06/20/2022 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 />