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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 Certification Date <br />10397599 11/14/24 <br />Facility Name <br />Sutter Tracy Community Hospital <br />Facility Address <br />1420 N. Tracy Blvd. <br />City <br />Tracy <br />ZIP Code <br />95376 <br />F2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Alltech Petro, Inc <br />Phone <br />209-559-1616 <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 />ICC Number <br />8146912 <br />ICC Expiration Date <br />10/16/26 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root #1336878 <br />08/24/26 <br />OPW #100456 <br />04/22/26 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />/ 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 />' <br />Date <br />11/14/24 <br />Total # of Pages <br />5 <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 />