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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 regularystem certification. <br /> I, FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181433 112/31 /19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building <br /> March Lane 76 <br /> Business Site Address City ZIP Code <br /> 2701 West March Ln . Stockton 95219 <br /> II, UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems, Inc. (408) 971 -2445 <br /> Mailing Address <br /> 680 Quinn Ave. , San Jose 95112 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the JCC Certification) <br /> Brian McPheely <br /> Contractor / Tank Tester License # IGC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /21 /2021 <br /> Monitoring System Training and Certifications iList all applicable certificationsj Expiration Date <br /> VR 11 /21 /2021 <br /> VMI 10/2912021 <br /> Red Jacket 2/8/2020 <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 /> 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.) Z El <br /> Was damage, debris , or liquid found inside any secondary containment systems? <br /> (if "Yes, " describe what was found in section lV 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, g <br /> r <br /> e of <br /> Removed Liquid from All STP Sumps . <br /> 5 <br /> NVIRor <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 = Califorria Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br /> i <br /> I <br /> I <br />