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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10182103 <br />Certification Date <br />3-16-23 <br />Facility Name <br />United Pacific #5446 <br />Facility Address <br />1403 Country Club Blvd <br />City <br />Stockton <br />ZIP Code <br />95204 <br />[2, SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />CGRS, Inc. <br />Phone <br />(916) 991-1100 <br />Mailing Address <br />5444 Dry Creek Road; Sacramento, CA. 95838 <br />Service Technician Performing Test <br />Garrett Warren <br />Contractor/Tank Tester License Number <br />CSLB#803616 <br />ICC Number <br />8185019 <br />ICC Expiration Date <br />12-19-24 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root Cert. #1342126 <br />12-2-24 <br />VMI LDT-890 Cert. #3822 <br />5-2-24 <br />Ronan Systems X-76 Leak Detection Monitors Cert. #76190501 <br />3-6-25 <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 />Service Technician Signature <br />Garrett Warren <br />Date <br />3-16-23 <br />Total # of Pages <br />12 <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 />