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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 />10184191 <br />Certification Date <br />11-06-2024 <br />Facility Name <br />A AND A GAS <br />Facility Address <br />1330 EAST YOSEMITE AVE <br />City <br />MANTECA <br />ZIP Code <br />95336 <br />F2.SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />ECO CHEK COMPLIANCE, INC. <br />Phone <br />1-888-500-2435 <br />Mailing Address <br />P.O. BOX 1394 LAFAYETTE, CA 94549 <br />Service Technician Performing Test <br />Felix Ramirez <br />Contractor/Tank Tester License Number <br />08-1740 Ex.05/31 /2026 <br />ICC Number <br />8883072 -UT <br />ICC Expiration Date <br />11/11/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root B34976 <br />7/5/2026 <br />Incon 1009883708 <br />12/11/2024 <br />VM 12517 <br />11/8/2025 <br />PNUEMERCATOR 10715 <br />05/17/2025 <br />SB BRAVO 2021-2929022 <br />01/26/2026 <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 />Fe&0(1IZ <br />Date <br />11-06-20246 <br />Total # of Pages <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 />