Laserfiche WebLink
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 /> 10180627 9/24/2024 <br /> Facility Name <br /> CHEROKEE GAS & MART ARCO <br /> Facility Address City ZIP Code <br /> 900 S CHEROKEE LANE LODI 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> ECO CHEK COMPLIANCE, INC. 1-888-500-2435 <br /> Mailing Address <br /> P.O. BOX 1394 LAFAYETTE, CA 94549 <br /> Service Technician Performing Test <br /> Felix Ramirez <br /> Contractor/Tank Tester License Number <br /> 08-1740 Ex.05/31/2026 <br /> ICC Number ICC Expiration Date <br /> 8883072-UT 11/11/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root B34976 7/5/2026 <br /> Incon 1009893708 12/11/2024 <br /> VM 1 2517 11/8/2025 <br /> PNUEMERCATOR 10715 05/17/2025 <br /> SB BRAVO 2021 -2929022 01/26/2026 <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 /> cyvtw 6Qav rez 9/24/2024 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 <br />