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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair Z 12 Month <br /> 1. FACILITY INFORMATION - - <br /> CERS ID Certification Date <br /> 1018 '161 0J 3} <br /> Facility Name — <br /> Ramos Oil Company <br /> Facility Address City ZIP Code <br /> 10842 S Harlan Road French Camp 195231 <br /> . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> JP Petroleum Service 916-37 693 J <br /> Mailing Address <br /> 3065 Asante Lane, West Sacramento Ca 95691 <br /> Service Technician Performing Test <br /> Gabe Garcia <br /> Cont rectorfTank Tester License Nurnber <br /> 81'1471 _ <br /> ICC Number ICC Expiration date <br /> 8413928 11012026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Man u cturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root 8J 0 6 <br /> OPW 812026 <br /> VMI 12/2026 <br /> 4. CERTIFICATION-BY SERVICE TECHNICIAN CONDUCTING TEST <br /> f hereby certify that the monitoring system is operational in accordance with California Code <br /> of Regulations, fitie 23, division 3, chapter 15, section 2638, that required supporting <br /> documentation is attached; and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> CERS = CafifomEa Environmental Repar#ing System, GP � Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SVV = Single <br /> - <br /> Walled,ailed, UDC = lUnder-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/PressureiHydrosta#ic <br /> Page 1 of 6 <br />