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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 /> Ix FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181447 06/02/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Speedway 4681 <br /> Business Site Address City ZIP Code <br /> 2500 W Lodi Lodi 95242 <br /> Ila 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 7/22/20 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root TLS3XXX 833709 3/25/2021 <br /> Vaporless Manufacturing Inc. #3225/1324 11 /1 /2020 <br /> Red Jacket # B33709 6/25/2020 <br /> FE PETRO # 1004933708 7/16/2020 <br /> III . RESULTS OF TESTING f 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) <br /> Was damage, debris , or liquid found inside any secondary containment systems? El FA El <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? [3 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 /> Replaced bad 794390420 sensor on Plus Tank - Tested & Passed . <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 /> f <br /> i <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br /> I <br />'s <br /> E <br />