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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 10181333 -73/30/2020 Business Name (Same as Facility Name or DBA-Doing Business As) Building # RUPI - LAKEWOOD CHEVRON Business Site Address City ZIP Code 236 HAM LANE LODI , CA 95242 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # (209 ) 744 - 0112 AFFORDA TEST Mailing Address 416 2ND STREET GALT , CA 95632 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) DAVID WINKLER Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 08 - 1739 Ex . 3/31 /20 8883059 - UT 1 /29/2020 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder Root 634975 2/7/2022 Incon 1009853708 11 /30/2020 III . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA ❑X MonitoringSystem Set-up ❑X Alarm Histo Report Was any monitoring equipment replaced ? El ❑X ❑ (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? ❑ X ❑ (If "Yes, " describe what was found in section IV below) Is all monitoring equipment operational per manufacturer's specifications ? ❑X ❑ ❑ (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, all passed Ji 1 -. i _. APR 0 C;" � � 20 ENVIRONMENTAL ►-IIEALTH DF"AFIff AENT 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