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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION Ll Installation LJ Repair M 12 Month <br /> 1. FACILITY INFORMATION <br /> GERS ID Certification Date <br /> 10166017 04/28/2023 <br /> Facility Name <br /> 7-ELEVEN#32190, MKT 2368 <br /> Facility Address City ZIP Cade. <br /> 4943 S. KINGSLEY(FRONTAGE RD)HWY 99 @ ARCH AIRPORT RD STOCKTON 195206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin, Tx 78759 <br /> Service Technician Performing Test <br /> Landon Zamora <br /> Contractor/Tank Tester License Number <br /> Class A General Engineering 743160 <br /> ICG Numb-er I ICC Expiration Date <br /> 9768392 06/08/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Late <br /> Veeder Root:ATG Technician (C28849) 04/03/2025 <br /> VMI:TLDT-5000 Tester(5126) 03/09/2024 <br /> Franklin Fueling:Phil-Tite EVR Ph 1 Systems(1021123713) 12/03/2023 <br /> PEI:RP1200(N/A) 06/05/2079 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify rhar the moniroring system is operational in accordance with Califon-ta 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 /> 04/28/2023 6 <br /> GERS = California Environmental Reporting System; GPH = Gallons Per Hour, ID = identification, <br /> ICC = International Code Council. LLD = Line Leah 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 />