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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM(Pagel of 6) <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy <br /> of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> agency regulating the USTs within 30 days of the date of the monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID of Monitoring System Certification <br /> Date <br /> 10181387 1/15/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> Ryder Stockton _ - --]_ <br /> Business Site Address City ZIP Code <br /> 3633 Duck Creek Drive Stockton 95215 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Balch Petroleum (408) 942-8686 <br /> Mailing Address <br /> 930 Ames Ave., Milpitas, CA 95035 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> Elmer Mortera <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 396575 5248052-UT 12/30/2019 <br /> Monitoring System Training and Certifications List all applicable certifications.) Expiration Date <br /> Veeder Root- Cert#: A28170 5/26/2020 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment Is capable of generating either. Y N NA <br /> ❑X Monitoring System Set-upxQ Alarm History Report <br /> Was any monitoring equipment replaced? o <br /> (If"Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) El <br /> Was damage, debris,or liquid found inside any secondary containment systems? <br /> (If'Yes,'describe what was found in section lV below.) N El El <br /> Is all monitoring equipment operational per manufacturer's specifications? <br /> (If'No,'describe why in section IV below.) <br /> IV. COMMENTS <br /> If directed to use this section,describe how and when the issues were or will be corrected. <br /> Liquid/rain water found: <br /> -New Oil Fill Sump <br /> -Diesel Main STP Sump <br /> -Diesel Reserve Fill Sump <br /> -UDC 1/2 <br /> -UDC 1 Slave <br /> All liquid cleaned out <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment Identified in this document was inspectediserviced in accordance with California Code of <br /> Regulations,Title 23,Division 3,Chapter 16,Section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is information(e.g.,manufacturers'checklists,monitoring system set-up,alarm history report,etc.)necessary <br /> to verify that this information and the site plan showing the layout of UST system Is complete and accurate. <br /> UST Service Technician Signature <br /> CERS=California Envi onmeental Reporting System,ID=klen9cation,ICC=International Code Council,Y=Yes,N=No,NA=Not Applicable <br /> UN-107 www.unldors.org 116-Rev.10/01118 <br />