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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 <br /> local agency regulating the USTs within 30 days of the date of the monitoring system certification . <br /> Is FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181335 2/20/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As .) Building # <br /> CHEVRON # 94275 <br /> CityBusiness Site Address ST ZlOCKTON 955207 <br /> 2905 W. BENJAMIN HOLT @ k5 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> TANKNOLOGY INC . (800) 8004633 Ext, <br /> Mailing Address <br /> 11000 N . Mopac Expressway #500 , Austin , TX 78759 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification .) <br /> Jesus Saldivar <br /> Contractor/Tank Tester License # 7ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/13/2021 <br /> Monitoring S steaining and Certifications (List all applicable certifications . ) Expiration1. <br /> Date <br /> Tanknology Certification Level III ATG Operability Training Certification Exam 115235 12/31 /2022 <br /> ICC CA UST Service Technician 8361393 06/13/2021 <br /> Veeder Root VR Level 4 845334 04/28/2021 <br /> VMI TLDT-5000 Tester 3802 11 /12/2021 <br /> 111 . RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating eifher. Fr� N NA <br /> Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced? r <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 /> Is all monitoring equipment operational per manufacturer's specifications? r, r r <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. j <br /> w <br /> - Lb <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 163 section 2638 and all information contained herein is true and accurate. Attached <br /> to this certification is information (e. g . , manufacturers' checklists , monitoring system set-up , alarm history report, etc. ) <br /> necessary 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 /> ank, ICC=International Code Council <br /> CERS=California Environmental Reporting System , ID=Identification , UST=Underground storage t <br />