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Appendix VI 245057 <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION rl Installation ® Repair [M 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181263 <br />Certification Date <br />9/19/2024 <br />Facility Name <br />Arco 6080 <br />Facility Address <br />85 E. Louise Ave. <br />City <br />Lathrop <br />ZIP Code <br />95330 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Gettler-Ryan Inc. <br />Phone <br />925-551-7555 <br />Mailing Address <br />6805 Sierra Court, Suite G., Dublin, CA 94568 <br />Service Technician Performing Test <br />Robert Jacobs <br />Contractor/Tank Tester License Number <br />220793 <br />ICC Number <br />8819943 <br />ICC Expiration Date <br />8/31/2026 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root ATG Tech Cert #C23345 <br />1/12/2025 <br />VMI MLLD Tech Cert #4400 <br />2/9/2025 <br />VMI LDT890 Tech Cert #4401 <br />2/9/2025 <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 />Date <br />9/19/2024 <br />Total # of Pages <br />3 <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 />