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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION Ll Installation Ll Repair M 12 Month <br /> �1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181231 02/05/2024 <br /> Facility Name <br /> 7-ELEVEN#43254/4945 <br /> Facility Address City ZIP Code <br /> 401 W KETTLEMAN LANE LODI 95240 <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 /> Jesus Saldivar <br /> Contractor/Tank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number ICC Expiration Date <br /> 8361393 05/16/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root:ATG Technician (645334) 04/03/2025 <br /> Veeder Root:Red Jacket Mechanical Line Leak Detector(645334) 08/10/2024 <br /> Franklin Fueling:FE Petro Submersible Pumps (1004283708) 08/11/2024 <br /> VMI:TLDT-5000 Tester(3802) 11/07/2025 <br /> OPW:EVR Phase 1 (104302) 01/04/2025 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> J hereby certify that the monitoring system is operational rn accordance with Caiifomia Code <br /> of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br /> documentarian is attached; and aR information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 02/05/2024 6 <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 />