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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 />1. FACILITY INFORMATION <br />CERS ID <br />Date of Monitoring System Certification <br />10181229 <br />1122/20 <br />Business Name (Same as Facitity !Name or DBA-Doing Business As) <br />Building # <br />Speedway 4873 <br />Business Site Address <br />City <br />ZIP Code <br />35 N. Cherokee Ln. <br />Lodi <br />95240 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />Phone # <br />Service Station Systems, Inc. <br />(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 iCC Certification) <br />Kristopher S Bell <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />485184 <br />8833000 <br />7/22/2020 <br />Monitoring System Trainin4 and Certifications List all applicable certifications.) Expiration Date <br />Veeder Root TLS 3XX 833709 3/25/2021 <br />Vaporless Manufacturing Inc #322511324 11/1/2020 <br />Red Jacket #B33709 6/25/2020 <br />FE PETRO #1004933708 7/16/2020 <br />III. RESULTS OF TESTING / SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />Z Monitoring System Set-up W1 Alarm History Report <br />Y <br />N <br />NA <br />Was any monitoring equipment replaced? <br />(lf "Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section W below.) <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />(lf 'Yes," describe what was found in section 1V below.) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />(lf No,"describe why in section W below.) <br />_ <br />IV. COMMENTS <br />If directed to use this section, describe how and when the issues were or will be corrected. <br />JAN 3 0 2020 <br />ALH ALTH <br />H <br />ENVIRONMENTAL <br />NVIRONMEN <br />DEPART MENT <br />V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />I 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 layout of UST system is complete and accurate. <br />UST Service Technician Signature <br />CERS = Cafrfornia Environmental Reporting System, ID = kientification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br />