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Appendix V! <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair Rx 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181387 1/2712022 <br /> Facility Name <br /> Ryder Truck Rental <br /> Facility Address City ZIP <br /> 3633 Duck Creek Road Stockton 195215 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Balch Petroleum (408) 942-8686 <br /> Mailing Address <br /> 930 Ames Ave. Milpitas, CA 95035 <br /> Service Technician Performing Test <br /> Rolando Urbina <br /> Contractor/Tank Tester License Number <br /> 396575 <br /> ICC Number ICC Expiration Date <br /> 8009631-UT 8/19/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root B38055 4/29/2023 <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 TechnicianSignatureDate __jTotal #of Pages <br /> iz � l- 1/27/2022 13 <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 /> UN-907 www.unidocs.org Rev.10/01/20 Page 1 of 6 <br />