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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION Installation Repair 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />Facility Name <br />Facility Address City ZIP Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />Mailing Address <br />Service Technician Performing Test <br />Contractor/Tank Tester License Number <br />ICC Number ICC Expiration Date <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <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 />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 <br />10181431 08/16/2022 <br />Manteca Valero <br />1700 E. Yosemite Ave. <br />Manteca 95336 <br />Tank-Tight Systems, Inc.(916) 378-4167 <br />8834817 11/14/2023 <br />08/16/2022 2 <br />1729 Crystal Ct., Olivehurst, CA 95961 <br />Brian Roth <br />1066914 A HAZ <br />Vaporless Mechanical Line Leak Detector #4186/4187 <br />Veeder Tec ATG Installer #A29945 <br />10/23/2023 <br />10/24/2023