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RECENED <br /> UNDERGROUND STORAGE TANK AUG 2 4 2020 <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 suba{1��� �QitOgad <br /> agency regulating the USTs within 30 days of the date of the monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10185183 7/29/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> Aisle 1 #2356 <br /> Business Site Address City ZIP Code <br /> 4219 Morada Stockton 95212 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Service Station Systems, Inc. (408)971-2445 <br /> Mailing Address <br /> 680 Quinn Ave.,San Jose 95112 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> Brian McPheely <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8822062 11/1/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root TLS 3XX B36745 11/21/2021 <br /> Vaporless Manufacturing Inc#3803 10/29/2021 <br /> Red Jacket#B36745 10/29/2021 <br /> FE PETRO#1014303708 11/21/2021 <br /> III. RESULTS OF TESTING /SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Z Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced? El 91 El <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? El 0 <br /> (If"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? <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 /> 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 /> CERS=California Environmental Reporting System,ID=Identification,ICC=International Code Council,Y=Yes,N=No,NA=Not Applicable <br />