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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> _ TYPE OF ACTION installation Repair F 12 Month <br /> I _ FACIL , €4dikATI0 - <br /> CERS ID Certification Date <br /> 9-23-2021---i <br /> Facility Name I <br /> i <br /> Gas and Shop Truck Stop (Gemco Truck Plaza - <br /> i Facility Address ' City ZIP Code <br /> l k 95366 <br /> 1902 E. Fr <br /> ontacle Road Ripon CA <br /> Ems( 1�CI IN I ON I <br /> Company Performing the Certification Phone <br /> Self Serve Petroleum _ -- 650 588-3088 <br /> Mailing Address <br /> 1045 Airport Blvd. South San Francisco <br /> Service Technician Performing Test <br /> Robert Neimeyer <br /> Contractor/Tank Tester License Number <br /> Gen A/ Haz 930666 <br /> [51 <br /> C Number ICC Expiration Date <br /> �. <br /> 10-11-2021 <br /> 4 <br /> I` NG AND CERT ;CATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date I <br /> 12-7-2021 <br /> Veeder Root level 4 . <br /> VMl 5-9-2022 <br /> I <br /> i <br /> CI f N IAN-.00tWUGTIN€a FEST 1 <br /> I 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 documentation is is attached;and all information contained herein is accurate. <br /> i Service Technician Signature ©ate Total # of Pages <br /> �¢ X% 9-23-2021 <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Cade 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 />