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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of s) <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 /> a enc regulating the USTs within 30 days of the date of the monitorings stem certification. <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10156819 5/ 14/19 <br /> Business Name ($ame as Facility Name or DBA-Doing Business As) Building # <br /> Safeway #2707 <br /> Business Site Address City ZIP Code <br /> 6425 N . Pacific Ave . Stockton 95207 <br /> Il. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems (408 ) 971 =2445 <br /> Mailing Address <br /> 680 Quinn Ave . San Jose, Ca 95112 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Kristopher Bell <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8833000 7/22/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Ex 1ration Date <br /> Veeder Root 3/25/2021 <br /> V. M . I 10/31 /2020 <br /> 111 . RESULTS OF TESTING ! SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Z 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 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 '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 /> Disp . #3/4 Diesel Union was weeping - Cleaned & Tightened . <br /> Removed Liquid from All Fill, STP , and Vent Sump . <br /> t <br />€[ <br /> R a }� <br /> JUNI 1 2019 <br /> i <br /> ENVIRONMENTAL HEALTH <br /> D RARTINIENT <br /> V . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 1 hereby certify that the equipment identified in this document was inspectediserviced 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 la out of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS = Cafrfomia Environmental Reporting System, ID = Identification, ICC = international Code Council, Y = Yes, N = No, NA = Not Applicable <br />