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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 /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181307 5/8/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> REFUEL CIRCLE K <br /> Business Site Address City ZIP Code <br /> 419 S. MAIN STREET �MANTECA, CA 95366 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> AFFORDA TEST (209) 744-0112 <br /> Mailing Address <br /> 416 2ND ST GALT, CA 95632 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> ZANE NIMMO <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 04-1676 Ex. 3/31/19 8883064-UT 6/1/2019 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A28446 9/28/2019 <br /> Incon 1009843708 11/30/2020 <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 /> 0 Monitoring System Set-up Q 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.) El X El <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.) <br /> IV. COMMENTS <br /> If directed to use this section,describe how and when the issues were or will be corrected. <br /> RECEIVED <br /> M 0 V 13 1 2019 <br /> ENVIRONMENTAL HEALTH <br /> DFPARTMENT <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 /> UST Service Technician Signature <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=International Code Council,Y=Yes,N=No,NA=Not Applicable <br />