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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) This form must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy 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 agency regulating the USTs within 30 days of the date of the monitoring system certification . I . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10180717 4/11 /19 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Fast & Easy Morada #60 (Stockton) Business Site Address City ZIP Code 10878 N Highway 99 Stockton 95212 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Confidence UST Services , Inc . ( 800 ) 339- 9930 Mailing Address 16250 Meacham Road , Bakersfield , CA 93314 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Timothy Capehart Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 804904 8414476 3/3/2020 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder root b47819 3/3/2020 III . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA XX Monitoring System Set-up Alarm History Report Was any monitoring equipment replaced ? (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) Ex El El Was damage , debris , or liquid found inside any secondary containment systems? 0 X❑ ❑ (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? N ❑ ❑ (If "No, " describe why in section IV below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. Found 91 #1 sump sensor not in the lowest point. It was repositioned by the technician and is now at the lowest point. Found Diesel STP with FX- 1 V leak detector, replaced with correct leak detector FX- 1 DV, retest with pass Found Unleaded leak detector failing initial test. It was readjusted and retested with passing results . Found 91 #2 product piping had a plugged clamshell . It was removed 4/12/2019 by technician Timothy Capehart. APR 9- 3 S K V. CERTIFICATION BY UST SERVICE TECHNICIAN CON DU d TI•iftfVOT1N 1.- I hereby certify that the equipment identified in this document was inspected/serviced in acco .4c . i I'fgrnia Code of Regulations , Title 23, Division 3, Chapter 16, Section 2638 and all information contained herein is true and a�c& rate ` Attached to this certification is information (e . g . , manufacturers' checklists , monitoring system set-up , alarm history report, etc .) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate . UST Service Technician Signature CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable UNA07 www, unidoes.org 1 /6 - Rev. 10/01 /18