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UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (page i of s) <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 monitorina system certification. <br />I. FACILITY INFORMATION <br />CERS ID <br />System Certification <br />J-Die"onitoring <br />10181579 <br />1/24/2020 <br />Business Name (Same as Facifity Name or DBA-Doing Business As) <br />Building <br />BAGLEY - TRACY UNIFIED SCHOOL <br />Business Site Address <br />City <br />ZIP Code <br />1970 W LOWELL ITRACY,CA <br />195376 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification Pho ne # <br />AFFORDA TEST (209) 744-0112 <br />Mailing Address <br />416 2ND STREET GALT, CA 95632 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />FELIX RAMIREZ <br />Contractor I Tank Tester License * <br />ICC Certification* <br />ICC Certification Epiration Date <br />08-1740 Ex.3/31/20 <br />I 8883072-UT <br />11/9/2020 <br />Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br />Veeder Root B34976 7/7/2020 <br />Incon 1009883708 11/30/2020 <br />III. RESULTS OF TESTING 1 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 />"Yes,"Identify <br />N(1f <br />the specific devices replaced end list the manufacturer and model for all replacement parts in section below.) <br />Was damage, debris, or liquid found inside any secondary containment systems? _ <br />"Yes,"describe <br />El <br />Q <br />(If what was found in section IV below.) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />dZ <br />El <br />El <br />(If Ido,"describe why In section IV below.) <br />IV. COMMENTS <br />X directed to use this section, describe how and when the Issues were or will be corrected. -'C <br />� F FA r _ <br />I TOUCH Certification completed by Hagley Enter. on site same daytime. Rl'� F <br />Tech: <br />Cert: 2020 <br />ENVIRONMENTAL HEALTH <br />DER/\PTMENT <br />I <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 s s e complete and accurate. <br />UST Service Technician Signature <br />G <br />CERS = Callorria Emu mnmer" Reporting System, 10 = Identification, ICC = trnkxrxbonai Code Cound, Y = Yes, N = No, NA= Not Applicable <br />