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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 /> 10180893 4/ 15/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Quik Stop MArket # 132 <br /> Business Site Address City ZIP Code <br /> 3555 W Hammer Lane Stockton 95219 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Walton Engineering , Inc . ( 916 ) 372- 1888 <br /> Mailing Address <br /> P . O . Box 1025 , West Sacramento , CA 95691 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the /CC Certification) <br /> Anthony Reyes <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8293772 9/ 16/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root Level 4 # 845115 1 / 17/2021 <br /> Bravo SWAT <br /> VMI Leak detection #3752 7/9/2021 <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 ❑X Alarm History Report <br /> Was any monitoring equipment replaced ? El <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) 11 <br /> Was damage , debris , or liquid found inside any secondary containment systems? <br /> (if "Yes, " describe what was found in section IV below.) El 0 El <br /> Is all monitoring equipment operational per manufacturer's specifications? X El El <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 /> i4 <br /> APR 3 0 2020 <br /> ENIVIRON : k '�i I kL Htzi,ALI.. H <br /> QEPA <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 r <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br />