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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION 0 Installation T Repair © 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181013 5-2-2024 <br /> Facility Name <br /> Quik Stop Market #120 <br /> Facility Address City ZIP Code <br /> 9321 Thornton Road Stockton 95209 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Walton Engineering, Inc. 916-373-1166 <br /> Mailing Address <br /> P.O. Box 1025, West Sacramento, CA 95691 <br /> Service Technician Performing Test <br /> Nicholas Janoe <br /> Contractor/Tank Tester License Number <br /> 617238 <br /> ICC Number ICC Expiration Date <br /> 8712764 12-13-2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root B49017 9-27-2025 <br /> Vaporless LDT 12-27-2025 <br /> Bravo 2021-2929572-NXT 11-19-2024 <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 Date Total # of Pages <br /> a_ 5-2-2024 11 <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 />