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Ei <br /> VFn <br /> UNDERGROUND STORAGE TANK JAN `,' 7 2020 <br /> MONITORING SYSTEM CERTIFICATION FORM <br /> I. FACILITY INFORMATION ENVIRONMENTAL HE LTH <br /> CERS ID Date: E)EFa.RTMEN <br /> 1/9/2020 <br /> Business Name Building# <br /> Kwik Sery <br /> Business Site Address City Zip Code <br /> 420 W Kettlennan Lodi <br /> ll. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing Test Phone#: <br /> BZ Service Station Maintenance 916-371-2380 <br /> Business Mailing Address <br /> 1401 Triangle Ct.,West Sacramento,CA 95691 <br /> Name of UST Service Technician <br /> Rhome Desbiens <br /> Contractor License#:433159 ICC Certification#: 5244364-UT ICC Certification Expiration Date: 1/4/2021 <br /> Monitoring System Training&Certification Expiration Date <br /> VR TLS 3xx-A22883 2/27/2021 <br /> VMI LD-2906 7/8/2020 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate&attach the following reports if the monitoring equipment is capable of generating either. Y N N/A <br /> ®Monitoring System Set-up ® Alarm History Report <br /> Was any monitoring equipment replaced? <br /> (if"Yes"identify the specific devices replaced and list the manufacturer&model for all replacement parts in section IV ❑ ® ❑ <br /> 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"No"describe why in section IV below.) ® El El <br /> IV. COMMENTS <br /> Describe how and when the issues were or will be corrected. <br /> Pumped small amount of water from DSL STP,all ok. <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hearby certify that the equipment identified in this document was inspected/serviced in accordance with California Regulations.Title 23,Division <br /> 3,Chapter 16,Section 2638 and all information contained herein is true and accurate.Attached to this certification is information(e.g. <br /> manufacturers'checklists,monitoring system set-up,alarm history report etc.)necessary to verify that this information and the site plan showing <br /> the layout of UST system is complete and accurate. <br /> UST Technician Signature <br />