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Appendix VI 21202049UndergroundStorageTank <br />Monitoring System Certification Form <br />TYPE OF ACTION fl Installation fl Repair 12 Month <br />1.FACILITY INFORMATION <br />r CERS ID Certification Date[10181235 7/6/2021 <br />Facility Name <br />Arco 5450 <br />Facility Address City ZIP Code <br />1617 W.Fremont Stockton 95203 <br />2.SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Gettler-Ryan Inc.925-551-7444 <br />Mailing Address <br />6805 Sierra Court,Suite G.Dublin,CA 94568 <br />Service Technician Performing Test <br />Darnell Smith <br />Contractor/Tank Tester License Number <br />220793 <br />ICC Number ICC Expiration Date <br />8709494 11/23/2021 <br />3.TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />Vender Root Tech Cert 0B48B57 3/28/2022 <br />VMI MLLD Tech Cert #4070 5/28/2023 <br />VMI LDTS9O Tech Cert #4071 5/28/2023 <br />4.CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <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 <br />documentation is attached;and all information contained herein is accurate. <br />Service Technician Signature Date Total #of Pages <br />7/6/2021 6 <br />CERS =California Environmental Reporting System,GPH =Gallons Per Hour,ID =Identification, <br />ICC =International Code 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