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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6 <br /> I Hill 11 <br /> Fae <br /> orm must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy <br /> 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 /> y regulating the USTs within 30 days of the date of the monitorings sty em certification. <br /> 1. FACILITY INFORMATION ' <br /> CERS ID Date of Monitoring System <br /> 10184805 10/ 16/18 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Rancho San Miguel <br /> Business Site Address City ZIP Code <br /> 610 Cherokee Lane 1 Lodi 195240 <br /> 11 . 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 /> Raamon Frazier <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8020732 2/7/2019 <br /> Monitoring System Training and Certifications (List all applicable certifications.) Expiration Date <br /> VR 7/6/2019 <br /> VMI 12/7/2018 <br /> 111. RESULTS OF TESTING / SERVICING _ <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N PIA <br /> Monitoring System Set-up ® Alarm History Report <br /> Was any monitoring equipment replaced? ® 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? <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 LIST 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 />