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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 />I. FACILITY INFORMATION <br />CERS ID <br />10180643 <br />Date of Monitoring System Certification <br />6/3/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Quik Stop Market <br />Building # <br />125 <br />Business Site Address <br />1580 W. Main Street <br />City <br />Ripon <br />ZIP Code <br />95366 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />Walton Engineering, Inc. <br />Phone # <br />(916) 372-1888 <br />Mailing Address <br />P.O. Box 1025, West Sacramento, CA 95691 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />Contractor / Tank Tester License # <br />617238 <br />ICC Certification # <br />8750053 <br />ICC Certification Expiration Date <br />10/24/2021 <br />Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br />Veeder-Root 3/3/2022 <br />Va orless - VMI 7/13/2020 <br />III. RESULTS OF TESTING / SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />❑x Monitoring System Set-up ❑x 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 />Was damage, debris, or liquid found inside any secondary containment systems? <br />(If "Yes, " describe what was found in section IV below.) <br />❑X <br />Is all monitoring equipment operational per manufacturer's specifications? <br />(If "No, " describe why in section IV below.) <br />X <br />L1 <br />El <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 verify that this information and the site plan showing the layout of UST system is complete and accurate. <br />UST Service Technician Signature <br />Ma,� tfr'ne,t <br />CERS = Califomia Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br />