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Appendix 5 254989 <br />Underground Storage Tank <br />Release Detection Equipment Testing Report Form <br />TESTING TYPE ❑ Installation ❑ Repair e 12 Month <br />1. FACILITY INFORMATION <br />DERS ID Test Date <br />10180733 I1012026 <br />Facility Name <br />Arco 7147 <br />Facility Address City ZIP Code <br />12060 ET, March Lane Stockton 195210 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing Testing <br />Phone <br />Nwestco LLC dba Oettler-Ryan <br />925-551-7558 <br />Mailing Address <br />8805 Sierra Court, Suite G. Dublin, CA 945608 <br />Service Technician Performing Testing — — <br />Gabriel Solodo <br />Contractor License Number <br />1073967 <br />ICD Certification <br />ICC Expiration Bate <br />0425282 <br />911412026 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Training Expiration Date <br />Veeder Root ATO Tech Cert #032271 <br />612712026 <br />VMI M LLD Tech Inert#5385 <br />6/MO 7 <br />VIII LD T891 Tech Cert #5356 <br />51312027 <br />4, CERTIFICATION BY SERVICE TECHNICIAN CONDUCTIN G TEST <br />i herebyr certify that aif equipment idenfifi"ed in this form has beers tested in accordance with <br />California Code o€ Regulations, title 23, division 3, chapter 16, section 2563; that required <br />supporting documentation is attached; and all information contained herein is accurate. <br />Service Technician Signature Date Total # of Pages <br />�-- 6/1 W2026 8 <br />C ERS = California Environ ental Reporting System, CPH = Gallons Per Hour, ID = Identification, <br />ICC = International Cade CobAd, LLD = Line Leak Detector, N = Not Applicable, UDC = Under - <br />Dispenser Containment, UST = Underground Storage Tanis, VPH = Vacuui /Pi-essure/Hydrostatic <br />Page 1 of 6 <br />