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Appendix VI <br /> Underground Storage Tank <br /> Monitoring, System Certification Form <br /> TYPE OF ACTION ® Installation r Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 2-28-2023 <br /> Facility Name <br /> Gas and Shop <br /> Facility Address City ZIP Code <br /> 1002 Frontage Road Ripon Ca 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Self Serve Petroleum 650 588-3088 <br /> Mailing Address <br /> 1045 Airport Blvd. S. San Francisco Ca 94080 <br /> Service Technician Performing Test <br /> Robert Neimeyer <br /> Contractor/Tank Tester License Number <br /> Gen A/ Haz 1096495 <br /> ICC Number ICC Expiration Date <br /> 5248067 10-9-2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root ATG 12-5-2023 <br /> VMI 5-1-2023 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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 S' nature Date Total # of Pages <br /> ✓� - 2-28-2023 <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 />