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TYPE OF ACTION ❑ Installation ❑ Repair 0 36 Month <br /> y Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ <br /> Repair (] 12 Month <br /> 1. FACILITY INFORMATIO14 <br /> Certification Date — <br /> CERS ID 02-12-2024 <br /> 10182251 <br /> Facility Name <br /> ARCH FiD AMPM <br /> L84 <br /> acility 55 S Address City ZIP Code <br /> I iWY 99 9STOGKTON 95215 <br /> 2. SERVIICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> ECH CHEK 888-500 CHEK <br /> Mailing Address <br /> P.O. BO,"K 1394 LAFAYETTE CA 94549 <br /> Service Technician Performing Test <br /> Felix Ramirez <br /> Contractor/Tank Tester License Number <br /> 08-1740 Ex.3/31/23 <br /> ICC Number ICC Expiration Date <br /> 8883072-UT 11/10/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root B34976 7/015/2024 <br /> Incon 1009883708 12/11/2024 <br /> rdocumenii <br /> IFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> certify that the monitoring system is operational in accordance with California Code <br /> tions, title 23, division 3, chapter 16, section 2638; that required supporting <br /> tation is attached; and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> Fe&PRaffl4.&4"*' 0e* 02-112-2024 E) <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leah; Detector, NA = Not Applicable, S\N = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuurrl/Pressure/Hydrostatic <br /> Page 1 of I <br /> 1/U r i r _ . <br />