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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (page f of 6) <br /> This form must be used to document testing and servicing of underground storage tank ( USTI 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 /> 6/ 18/2019 <br /> Business Name (Same as Facility !Jame or DBA-Doing Business As) Building # <br /> Arco 7147 _ <br /> Business Site Address city ZIP Code <br /> 1206 E . March Lane Stockton 195210 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Gettler- Ryan Inc . (925 ) 551 -7555 <br /> Mailing Address <br /> 6805 Sierra Ct . Suite G , Dublin , CA 94568 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> David Rause <br /> Contractor f Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 612810202 <br /> Monitoring SyslTm7raininq and Certifications ftlstall applicable certifications ) Expiration Dale <br /> Veeder Root Tech Cert # B44848 7/2/2020 <br /> VMI Line Leak Cert # 3625 _ 9/7/2020 <br /> VMI LDT-890 Leak Detector Test Cert #3626 9/7/2020 <br /> III . RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Q Monitoring System Set-up CJx Alarm HistoryReport <br /> Was any monitoring equipment replaced? O <br /> (If 'Yes. " identify the specific devices replaced and list the manufacturer and model for ail replacement parts in section 1V below ) <br /> Was damage , debris , or liquid found inside any secondary containment systems'? <br /> (if ' Yes. " describe what tvas found in section IV below ) <br /> Is all monitoring equipment operational per manufacturer's specifications9 Q <br /> (If "Na, .' describe why in section IV below ) <br /> IV. COMMENTS <br /> It directed to use this section describe how and when the issues were or will be corrected <br /> RECEJI ' <br /> JUL 0 3 2019 <br /> ENVIRONMEfNITAL HEALTH <br /> DEPARTMENT <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 . , manufacturers' checklists , monitoring system set- up, alarm history report , etc . ) necessary <br /> to verifV that this information and the site plan is owinqtfle layout of UST system is complete and accurate. <br /> UST Service Technician S.gnature <br /> CERS = California Environmental Reporting System ID = Iden9catlon, iCC = International Code Council Y = Yes. N = No, NA = Not Applicable <br />