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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel of 6) <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy <br /> of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> agency regulating the USTs within 30 days of the date of the monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 1/22/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> Arco 6080 <br /> Business Site Address City ZIP Code <br /> 85 E Louise Ave Lathrop 95330 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Gettler Ryan inc (925) 551-4777 <br /> Mailing Address <br /> 6808 Sierra Ct . Dublin, CA 94568 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the iCC Certification) <br /> David Rouse <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 220793 8292530 6/28/2020 <br /> monitorin S stem Training and Certifications List all apeficable certiricalions Expiration Date <br /> Veeder Root TLS3XXX Technician 644848 7/2/2020 <br /> VMI Line Leak #3625 9/7/2020 <br /> VMI LDT-890 Leak Detector Tester#3626 9/7/0202 <br /> — <br /> Ill. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generatite <br /> either. <br /> []x MonitoringSystem Set-upAlarm Histo ort Y N NA <br /> Was any monitoring equipment replaced? ❑ El ❑ <br /> (if"Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section 11/below) <br /> Was damage,debris, or liquid found inside any secondary containment systems? El ❑ <br /> (1f"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? PI <br /> (11"No,"describe why in section IV below) ❑ <br /> IV. COMMENTS <br /> ltdirected to use this section,describe how and when the issues were or will be corrected <br /> FEB 0 7 2019 <br /> EN\1IRONMENTAL HEAL--"-' <br /> OEPARTMENT <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br /> Regulations,Title 23,Division 3,Chapter 16,Section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is information(e.g., manufacturers'checklists, monitoring system set-up,alarm history report,etc.) necessary <br /> to verify that this information and the site plaMhowiiaofte layout of UST system Is complete and accurate. <br /> UST Service Techn.cian Signature <br /> bV <br /> CERS=Caldomia Erntionmental Reporting System,ID=Identification,ICC=international Code Council,Y=Yes,N=No,NA=Not Applicable <br />