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UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (Page � of s) <br />This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form <br />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 <br />USTs within 30 days of the date of the monitoring system certification. <br />I. FACILITY INFORMATION <br />CERS ID <br />10181267 <br />Date of Monitoring System Certification <br />10/5/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As.) <br />Stockton Army Aviation Support Facilit <br />Building # <br />Business Site Address <br />2000 Stimson Road <br />City <br />Stockton <br />ZIP Code <br />95206 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />Tank Team, Inc. <br />_ <br />Phone # <br />(805) 432 - 0216 Ext. <br />Mailing Address <br />2745 Sherwin Ave., Ste.8, Ventura, CA 93003 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br />Bernard Olson <br />Contractor/Tank Tester License # <br />Eng A, C-10, C-57 512835 <br />ICC Certification # <br />5252993 UT <br />ICC Certification Expiration Date <br />9/20/2019 <br />Monitoring System Training and Certifications (List all applicable certifications.) <br />Veeder-Root A28591 <br />Expiration Date <br />10-19 <br />Vaporless Manufacturing ,Inc. <br />10/19 <br />III. RESULTS OF TESTINGISERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />❑Monitoring System Set-up ❑Alarm History Report <br />Y <br />N <br />NA <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 />❑ <br />® <br />❑ <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />(If "Yes, "describe what was found in section IV below.) <br />❑ <br />® <br />❑ <br />is all monitoring equipment operational per manufacturer's specifications? <br />(If "No, "describe why in section IV below.) <br />❑ <br />® <br />❑ <br />IV. COMMENTS <br />If directed to use this section, describe how and when the issues were or will be corrected. <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 verif that this information and the site � show the l� out UST system is complete and accurate. <br />UST Service Technician Signature - -^ / <br />CERS = California Environmental Reporting System, ID =Identification, ICC = International Code Council, Y = Yes, N = No, NA =Not applicable <br />