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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION F71 Installation ❑ Repair ❑✓ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10156809 <br />Certification Date <br />4/4/24 <br />Facility Name <br />Safeway 1769 <br />Facility Address <br />2802 Country Club Blvd <br />City <br />Stockton <br />ZIP Code <br />95204 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Service Station Systems <br />Phone <br />(408) 971-2445 <br />Mailing Address <br />680 Quinn Ave San Jose CA 95112 <br />Service Technician Performing Test <br />Stephen Ingraham <br />Contractor/Tank Tester License Number <br />485184 <br />ICC Number <br />10193405 <br />ICC Expiration Date <br />3/24/26 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root # C31685 <br />7/19/24 <br />Franklin Fueling # 1006623714 <br />4/1/26 <br />Vaporless # 5220 <br />7/28/24 <br />Vaporless (MLLD) # 5219 <br />7/28/24 <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 />Date <br />4/4/24 <br />Total # of Pages <br />6 <br />CERS = California Environmental Reporting S <br />ICC = International Code Council, LLD = Line <br />Walled, UDC = Under -Dispenser Containment, <br />VPH = Vacuum/Pressure/Hydrostatic <br />ystem, GPH = Gallons Per Hour, ID = Identification, <br />Leak Detector, NA = Not Applicable, SW = Single - <br />UST = Underground Storage Tank, <br />Page 1 of 6 <br />