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t t <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181387 111512019 <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 195215 <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 /> Ill. 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 <br /> Monitorinq System Set-up Alarm History Report <br /> Was any monitoring equipment replaced? <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) <br /> Was damage, debris, or liquid found inside any secondary containment systems? <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? <br /> (if oft, " describe why in section IV below.) NX El 1:1 <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 /> tlA <br /> - New Oil Fill Sump <br /> - Diesel Main STP Sump 1 <br /> - Diesel Reserve Fill Sump <br /> - UDC 1 /2 <br /> - UDC 1 Slave <br /> All liquid cleaned out <br /> R <br /> g <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced 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 /> LIST Service Technician Signature -- <br /> CERS = California EmAronrrental Reporting System, ID = Identification, ICC = International Code Cound, Y = Yes, N = No, NA = NotApplicable <br /> UN-107 www. unidoes.org 116 - Rev. 10/01118 <br />