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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ® Installation Repair iF 12 Month <br /> - - <br /> ^�. FtJdRfiAlfi`fIt7N — — <br /> CERS ID Certification Date <br /> 9-23-2021 <br /> Facility Name <br /> Gas and Shop Truck S (Gemco Truck_Plaza ZIP Code <br /> Facility Address City <br /> 1002E Fronta e� Road-. Ri 95366 <br /> 2 SERV Tibi,! ICIAN IN06RMATION <br /> � x <br /> Company Performing the Certification Phone <br /> Self Serve Petroleum (650 588-3088 <br /> Mailing Address <br /> 045 Air i <br /> Service Technician Performing Test <br /> Robert <br /> Contractor/Tank Tester License Number <br /> Gen A/ Haz 930666 <br /> ICC Number ICC Expiration Date <br /> 4 10-11-2021 <br /> 416ERTMCA N9 <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> 12-7-2021 <br /> VMI 5-9-2022 <br /> *� GE TECHNICIArQ ONDUCTING TEST <br /> Irhereby rtify that the monitoring system is operational in accordance with California Code <br /> ions, 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 /> 9-23-2021 <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 />