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Appendix Vi 20204729 <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ® Installation Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10182141 12/31/2020 <br /> Facility Name <br /> Arco 2186 <br /> Facility Address City ZIP Code <br /> 3212 N. Lalifornia Stockton 95204 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Gettler-Ryan Inc. 925-551-7555 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G, Dublin, CA 94568 <br /> Service Technician Performing Test <br /> Terrell Taylor <br /> Contractor/Tank Tester License Number <br /> 220793 <br /> ICC Number ICC Expiration Date <br /> 9315756 8/23/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root Tech Cert#C27879 7/30/2022 <br /> VMI Line Leak Detector Tech Cert#4849 12/22/2022 <br /> VMI LDT-890 Leak Detector Tester Cert#4848 12/22/2022 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitoring system is operational in accordance with California 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 Technician Signature Date Total# of Pages <br /> 12/31/2020 6 <br /> or <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 />