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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6 <br /> This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy <br /> of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> agency regulating the USTs within 30 days of the date of the monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 1 /3/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Arco 2186 <br /> Business Site Address City ZIP Code <br /> 3212 N California Stockton 195204 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Gettler Ryan Inc (925 ) 5514777 <br /> Mailing Address <br /> 6808 Sierra Ct . Dublin , CA 94568 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the iCC Certification) <br /> David Rouse <br /> Contractor i Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 6/28/2020 <br /> Monitoring System Training and Certifications List all applicable certificalions. Expiration Date <br /> Veeder Root TLS3XXX Technicians B44848 7/2/2020 <br /> VMI Line Leak #3625 9/7/2020 <br /> VMI LDT- 890 Leak Detector Tester # 3626 <br /> III . RESULTS OF TESTING i SERVICING <br /> indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Monitoring System Set-uAlarm History Report <br /> Was any monitoring equipment replaced ? El N <br /> (if "Yes, " identify the specirrc devices replaced and list the manufacturer and model for all replacement parts in section iV below.) <br /> Was damage , debris , or liquid found inside any secondary containment systems? 0 Q <br /> El <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? Z El <br /> (11"No, " describe why In section IV below,) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> .,--` CE1Vr D <br /> JAN 2 2 2019 <br /> TH <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment Identified In this document was inspectediserviced in accordance with California Code of <br /> Regulations , Title 23 , Division 3 , Chapter 16, Section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is information (e.g., manujactu checklists, monitoring system set-up , alarm history report, etc. ) necessary <br /> to verify that this information d the sitoffilan wing the layout of LIST system is complete and accurate. <br /> UST Service Technician Signat <br /> CERS = CaWnia Enwonmental Reporting System, iD = Identification, [CC = International Cade Coundi, Y = Yes, N = No, NA = Not Applicable <br />