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Appendix A <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />® 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10184725 <br />Certification Date <br />3/28/2023 <br />Facility Name <br />Chevron <br />Facility Address <br />2615 Grantline Rd. <br />City <br />Tracy <br />ZIP Code <br />95304 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Pinnacle Fuel Compliance <br />Phone <br />408-206-9840 <br />Mailing Address <br />P.O. Box 32849 <br />Service Technician Performing Test <br />Jeff Conger <br />Contractor/Tank Tester License. Number <br />90-1116 <br />ICC Number <br />1081782 <br />ICC Expiration Date <br />11/10/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veederoot TLS-3XX <br />1/11/2025 <br />Franklin Fueling — FE Petro <br />2/22/2025 <br />Vaporless Manufacturing LDT-890 Tester <br />9/12/2024 <br />Vaporless Manufacturing LD Installation & Replacment <br />9/12/2024 <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 <br />d <br />Date <br />3/28/2023 <br />Total # of Pages <br />15 <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 />