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UNDERGROUND STORAGE TANK <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 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 /> h FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181407 1 /9/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Kwik Sery <br /> Business Site Address _ City ZIP Code <br /> 420 W . Kettleman Ln . Lodi 195240 <br /> II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems (408) 971 -2445 <br /> Mailing Address <br /> 680 Quinn ave San Jose Ca , 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 # ICG Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /9/2019 <br /> Monitoring System Training and Certifications List all applicable certifications. Ex iration Date <br /> VR B36745 2/27/2020 <br /> VMI 11 /29/2019 <br /> Ill . RESULTS OF TESTING I SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> ® Monitoring System Set-up ® Alarm History Report <br /> Was any monitoring equipment replaced ? ® ❑ <br /> Ej <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section N below.) <br /> Was damage , debris , or liquid found inside any secondary containment systems? ® El M <br /> (If "Yes, " describe what was found in section IV below,) <br /> Is all monitoring equipment operational per manufacturer' s specifications ? Z El ❑ <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 /> Removed liquid from all UDC 's and 87 , 91 and DSL STP Sumps . <br /> Replaced 87 leak detector LD 2000 - Retested & Passed . <br /> Upon Completion of Testing made sure 87 STP Sensor, 91 STP Sensor, UDC 1 /2 & 5/6 Sensors All Plac i . Ccrxeo Wo t n y <br /> F [ B 0 6 2019 <br /> NVI � *I �, FNN 9AL 11EALT1 <br /> ; � �� 1 <br /> ,_ , . <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 /> j CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br /> I <br /> i <br />