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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIF CATION FORM ( Page 1 of 6) <br /> This form must be used to document testing and servicing of under Iround storage tank ( UST) monitoring equipment. A copy <br /> of this form must be provided to the UST owner or operator. Theo ner 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 monitol 'ing system certification . <br /> I . FACILITY INFORMATION <br /> CERS ID <br /> Date of Monitoring System Certification <br /> Business Name (Same as Facility Name or DBA 2/14/ 19 <br /> -Doing Business As) Building # <br /> AG SPANOS JET CENTER <br /> Business Site Address Cit <br /> 4800 S . AIRPORT WAY y ZIP Code <br /> STOCKTON , CA 95208 <br /> II . UNDERGROUND STORAGE TANKSERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification <br /> AFFORDA TEST Phone # <br /> (209 ) 744 -0112 <br /> Mailing Address <br /> 416 2ND ST . GALT, CA 95632 <br /> Name of UST Service Technician Performing the Certification (Print as shown on th 3 ICC Certification) <br /> EDWARD STEARNS <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 88830804T 11 /9/2020 <br /> Monitoring System Traininq and Certifications List all applicable certifications. <br /> Veeder Root A31048 Ex iration Date <br /> Incon 1009893708 6/3/2020 <br /> 11 /30/2020 <br /> III . RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports if the monitoring equipments capable of generating either. <br /> OX Monitoring System Set-up OX Alarm History Report Y N 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.) 0 ❑ <br /> Was damage, debris , or liquid found inside any secondary containment systems? <br /> (If "Yes, " describe what was found in section IV below.) ❑ 0 ❑ <br /> Is all monitoring equipment operational per manufacturer' s specifications? <br /> (If "No, " describe why in section IV below.) El El <br /> IV. COMM NITS <br /> If directed to use this section, describe how and when the issues were or will be corrected, <br /> V. CERTIFICATION BY UST SERVICE TECH 41CIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was ir spected/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 U T system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS = Calffomia Environmental Reporting System, ID = Identification, ICC = Intemational Code Council, Y = Yes, N = No, NA = Not Applicable <br />