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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <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 />TYPE OF ACTION Installation Repair 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10180759 <br />Certification Date <br />4/17/2024 <br />Facility Name <br />AXIS MSO #6822 <br />Facility Address <br />2132 MARIPOSA RD <br />City <br />STOCKTON <br />ZIP Code <br />95205 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />TANK-TEK ENVIRONMENTAL CORP <br />Phone <br />951.779.4999 <br />Mailing Address <br />PO BOX 5850, RIVERSIDE CA 92517 <br />Service Technician Performing Test <br />ROBERT SLUNAKER <br />Contractor/Tank Tester License Number <br />803705 <br />ICC Number <br />8041107 <br />ICC Expiration Date <br />7/8/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />VMI LDT-890 CERT #4023 2/17/2025 <br />VEEDER-ROOT TLS-3XX 2/28/2025 <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 <br />4/17/2024 <br />Total # of Pages <br />6