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Ll <br /> n ,u <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) A I I Q I ,y r r� <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 certificatior!� � r f <br /> I . FACILITY INFORMATION � , <br /> CERS ID Date of Monit rH S s e e i ica ion <br /> 10726990 8 /25/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Pilot 1017 Lathrop <br /> Business Site Address City ZIP Code <br /> 345 Roth Rd . French Camp 195231 <br /> Ii . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Jones Covey Group Inc . (888 ) 972 - 7581 <br /> Mailing Address <br /> 9595 Lucas Ranch Rd # 100 Rancho Cucamonga Ca , 91730 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Jose Ochoa <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804431 8004551 - UT 10/28/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder- Root - B35931 11 /6/2021 <br /> VMI - 3032 9/3/2021 <br /> III . RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> Y N NA <br /> N Monitoring System Set- up Alarm History Report <br /> Was any monitoring equipment replaced ? <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section lV below.) El FX El <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) FX 0 El <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 /> 1 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 />