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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Paget 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 /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10182137 3/13/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> GEORGE'S MINI MART <br /> Business Site Address City ZIP Code <br /> 18662 HWY 88 �LOCKEFORD, CA 95237 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> AFFORDA TEST (209) 744-0112 <br /> Mailing Address <br /> 416 2ND ST GALT, CA 95632 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> DAVID WINKLER <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex. 3/31/20 8883059-UT 1/29/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root 634975 2/8/2020 <br /> Incon 1009853708 11/30/2020 <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 /> ❑x Monitoring System Set-up ❑x 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 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.) X El El <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> ZUNA ON SITE WITH SJV ALL PASSED <br /> MAR 21 2019 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMC."'T <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 />