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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <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 />TYPE OF ACTION Installation Repair 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />Facility Name <br />Facility Address City ZIP Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Mailing Address <br />Service Technician Performing Test <br />Contractor/Tank Tester License Number <br />ICC Number ICC Expiration Date <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <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 />10181447 6/5/23 <br />Speedway 4681 <br />2500 W Lodi Lodi 95242 <br />Service Station Systems (408) 971-2445 <br />680 Quinn Ave San Jose CA 95112 <br />Kris Bell <br />485184 <br />8833000 7/22/24 <br />Veeder root TLS- 3xx # B33709 2/16/25 <br />Vaporless Manufacturing Inc #1324/3225 8/17/24 <br />Red Jacket #B33709 5/26/24 <br />Franklin Fueling Site Safety #1004933708 6/20/24 <br />FE Petro #1004933708 6/20/24 <br />6/5/23 6