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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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181387 1 1 /9/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Ryder Fuel Services <br /> Business Site Address City ZIP Code <br /> 3633 Duck Creek Rd . Stockton 195215 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Balch Petroleum (408 ) 942-8686 <br /> Mailing Address <br /> 930 Ames Ave . Milpitas , CA 95035 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Robert Henninger <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 369575 5252265- UT 6/21 /2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder- Root TL&3XX Technician A25027 3/31 /2021 <br /> Ill . RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> �x <br /> Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced ? El RX F <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? RX 1:1 El <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? NX El 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. <br />` Liquid was found in the following sumps and UDC's : <br /> i <br /> T1 - Diesel STP Sump = 3 cups water <br /> I T1 - Diesel Fill Sump = 1 cup water <br /> i <br /> T2 - Diesel Reserve Fill Sump = 5 cups water <br />( T3 - Used Oil = 2 cups water <br /> UDC 1 /2 Master = 1 /2 cup diesel <br /> UDC 2 Slave = 1 /2 cup diesel <br /> UDC 4 Master = 1 /2 cup diesel <br /> *All liquid was removed and disposed of per Ryder's protocol . <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 <br /> -plan <br /> +showing the layout of UST system is complete and accurate . <br /> UST Service Technician Signature <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = Intemational Code Council, Y = Yes, N = No, NA = Not Applicable <br /> UN-107 www. unidoes.org 1 /6 - Rev. 10/01 /18 <br />