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Appendix VI 2021 3824 <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION rI Installation © Repair 12 Month <br /> FFFA'CILITY INFORMATION <br /> CERS ID Certification Date <br /> 10339507 _ 11/19/2020 <br /> Facility Name <br /> Arco 7049 <br /> Facility Address ; City ZIP Code , <br /> 800 E. Kettleman Lane Lodi _ 95240_ <br /> 12. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Gettler-Ryan Inc. (925)551-4777 <br /> Mailing Address <br /> 6805 Sierra Ct., Suite G, Dublin, CA <br /> Service Technician Performing Test <br /> Darnell Smith <br /> Contractor/Tank Tester License Number <br /> 220793 _ <br /> ICC Number ICC Expiration Date <br /> 87094941'112312021 <br /> _ I <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VMI LD Tester#4071 5/27/2021 <br /> VMI Cert#4070 6/12/2021 <br /> Veeder Root#B48857 3/23/2022 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitoring systemisoperational in accordance with Califomia 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 Technic' atw� Date Total # of Pages <br /> ,:�� 11111912020 6 <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 />