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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <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 /> <br />Page 1 of 6 <br />TYPE OF ACTION ☐ Installation ☐ Repair ☒ 12 Month <br />1. FACILITY INFORMATION <br /> <br />CERS ID <br />10397599 <br />Certification Date <br />11/18/21 <br /> <br />Facility Name <br />Sutter Tracy Community Hospital <br /> <br />Facility Address <br />1420 N. Tracy Blvd. <br />City <br />Tracy <br />ZIP Code <br />95376 <br /> <br />2. SERVICE TECHNICIAN INFORMATION <br /> <br />Company Performing the Certification <br />Alltech Petro, Inc <br />Phone <br />209-532-7320 <br /> <br />Mailing Address <br />P.O. Box 4208 Sonora Ca, 95370 <br />Service Technician Performing Test <br />Isaac Anderson <br />Contractor/Tank Tester License Number <br />CA 623541/09-1749 <br /> <br />ICC Number <br />8146912 <br />ICC Expiration Date <br />09/10/22 <br /> <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />Veeder-Root Level IV #B36878 09/05/22 <br />OPW #100456 05/11/22 <br /> <br /> <br /> <br /> <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I 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 /> <br />/Service Technician Signature Date <br />11/18/21 <br />Total # of Pages <br />5 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />