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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 10181355 3/3/2020 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Hammer Lane Valero Business Site Address City T95'210 P Code 1210 East Hammer Lane Stockton II . 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 # rtification # ICC Certification Expiration Date 717 804904 8414476 2/25/2020 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder- Root B47819 8/17/2020 III . RESULTS OF TESTING I SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. y N NA ❑x 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.) Was damage , debris , or liquid found inside any secondary containment systems? ❑ 0 El (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer' s specifications? FX1 0 ❑ (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. Electronic monitoring certification r Ix L E NV 11 V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations , Title 23, Division 3 , Chapter 16 , Section 2638 and all information contained herein is true and accurate . 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