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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION 0 Installation Repair 12 Month <br /> [li-7FA_CI LITY INF0RMAT10IN <br /> EIS Ip Certification Data <br /> /0181343 O61261202 <br /> Facility Flame <br /> West Lane Chevron <br /> Facility Address Oity ZIP Code <br /> � tiest Lane Stockton 9510 <br /> 2. SERVICE TECHNI CIAN 1INFORMATION <br /> Company Performing the Certification Phone <br /> Elite IV Contractors (209)-461fi337 <br /> Mailing Address <br /> 2525 Wigwam Dr. Stockton, CA. <br /> Service Technician Performing Test <br /> Ernesto Esqueda <br /> o nt ractor/Ta n k Tester License INumber <br /> 100'1331 <br /> ICC Number IOC Expiration hate <br /> 10399647 0311912027 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Foot ATC C 35653 0411212026 <br /> 4. CERTIFICATION BY SERVICE TEC HNIOI N CONDUCTING TEST <br /> l hereby certify that the monitoring systern is operational in accordance with Catifornia Code <br /> of Regufalions, title 23, division 3, chapter 16, se0ion 638; that required supporting <br /> do cum entatlon is attached; and all informartlon contained herein is accurate-. <br /> Service Technician Signature Date Total# of Pages <br /> 061 612025 6 <br /> CERS = 0 aIifornia Environmental Reporting System, G PH = Gal Ion s Per Hour, ID = Identification, <br /> I G 0 = International Code Council, LLD = Lime Leak Detector, NA = Not Applicable, SW = Single- <br /> 1 ailed, UDG = Under-Dispenser Containment, L)ST = Underground Storage Tank, <br /> VIP = 1lacuurnfPressnre1Hydrostatic <br /> Page I of 6 <br />