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Appendix VI <br /> Underground Storage Tank <br /> Monitoring y ifi ati n Form <br /> TYPE OF ACTION ❑Installation ❑Repair ®12 Month <br /> k <br /> 1. FACILITY INFORMATION <br /> i <br /> 5 <br /> CERS ID Certification Date <br /> 04/11/2023 <br /> Facility Name <br /> Manteca Chevron W.O. 170702 <br /> Facility Address City ZIP Code <br /> 1257 W. yosemite Ave Manteca 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Franzen-Hill (559) 688-2977 <br /> Mailing Address <br /> 1100 N J Street <br /> Service Technician Performing Test <br /> JUNIOR SINCO <br /> Contractor/Tank Tester License Number <br /> A304147 <br /> ICC Number ICC Expiration Date <br /> 5246152 10/17/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VEEDER ROOT CERT#A30660 05/09/2023 <br /> RED JACKET MLLD CERT#A30660 05/06/2023 <br /> VMI CERT# 2138 & 2137 05/-5/2023 <br /> INCON L5 CERT# 1011663708 05/28/2023 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the monitoring system is operational in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 96, section 2638; that required supporting documentation is <br /> attached;and all information contained herein is accurate. <br /> Service Techni Si ature Date Total # of Pages <br /> 04/11/2023 6 <br /> 5. MONITOIVNG SYSTEM AND PROGRAMMING <br /> i <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 />