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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION 11 Installation I_1 Repair Q 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Certification Date <br />11/08/2021 <br />Facility Name <br />Stockton <br />Facility Address <br />1990 Picccli Road <br />Gity <br />Stockton <br />ZIP Code <br />95215 <br />2. SERVICE TECHNICIAN INFORMATION <br />Com�an+ Performing the Certification <br />Tanknol gy, In . <br />Phone <br />800-964-1250 <br />Mailin�q Address <br />11000 N opac Expy #500 Austin, Tx 78759 <br />Service Technician Performing Test <br />Brent Bowen <br />ContractorlTank Tester License Number <br />Class A General Engineering 743160 <br />ICC Number <br />8211862 <br />ICC Expiration Date <br />06/08/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />ICC:CA UST Service Technician <br />06/08/2023 <br />ICC:ICC UST Tank Tightness Testing <br />06/22/2023 <br />OPW:EVR Phase 1 <br />01/05/2022 <br />Veeder Root:VR Level 4 <br />04/23/2023 <br />VM I:TLDT-5000 Tester <br />08/11/2023 <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 98, section 2638; that required supporting <br />documentation is attached; and all information contained herein is accurate. <br />Service Technician Signature <br />Date <br />11/08/2021 <br />Total # of Pages <br />7 <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 />