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19202880 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page i of 6) <br /> William 1111 :1 <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 /> a enc 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 /> 10181087 8/26/2019 <br /> Business Name (Same as Facility Name or DBA - Doing Business As) Budding # <br /> Arco 2093 <br /> Business Site Address City ZIP Code <br /> 3425 Tracy Blvd . Tracy 195376 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Cerllficaton Phone # <br /> Gettler- Ryan Inc . (925 ) 551 -7555 <br /> Mailing Address <br /> 6805 Sierra Court , Suite G , 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 Systjm�Traininq and Certifications List all applicable certifications ) Expiration Date <br /> Veeder Root Tech Cert #B44B48 7/2/2020 <br /> VMI Line Leak Detector Test Tech Cert #3625 9/7/2020 <br /> VMI LDT-890 Leak Detector Tester Tech 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 /> x Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced ? <br /> (if "Yes, '" identify the specific 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? a <br /> (If "Yes, " describe what was found in section IV below ) <br /> Is all monitoring equipment operational per manufacturer' s specifications? <br /> (ff "No. " describe why in section 1V below ) <br /> IV. COMMENTS <br /> If directed to use this section. describe how and when the issues were or will be corrected <br /> ya <br /> OE '.aIJ ' <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' c ecklists , monitoring system set-up, alarm history report, etc .) necessary <br /> to verify that this information and the site Iola# sho the layout of UST system is complete and accurate . <br /> UST Service Technician Signature <br /> CERS = California Environmental Reporting System 1D = IdenUficahon, ICC = International Code Council. Y = Yes N = No NA = Not Applicable <br />