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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 of this form <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br /> 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 /> 10181019 11/01/2019 <br /> Business Name(Same as Facility Name or DBA—Doing Business As.) Building# <br /> Tracy Market <br /> Business Site Address City ZIP Code <br /> 15 E. Grant Line Road Tracy, CA 195376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> ECO-CHEK Compliance, Inc. (888) 500- 2435 Ext. 2 <br /> Mailing Address <br /> P.O. Box 1394, Lafayette, CA 94549 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification.) <br /> Marco Alejos <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 958763 8415074 04/27/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root Level 2/3#C26930 06/19/2021 <br /> Va orless LDT-890#4451 05/10/2021 <br /> S Bravo#SWAT 04/10/2022 <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 /> ®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 IV below.) E El El <br /> Was damage,debris,or liquid found inside any secondary containment systems? <br /> (If"Yes,"describe what was found in section IV below.) El Z El <br /> Is all monitoring equipment operational per manufacturer's specifications? <br /> (If"No,"describe why in section IV below.) E El El <br /> IV. COMMENTS <br /> If directed to use this section,describe how and when the issues were or will be corrected. <br /> Replaced Tank 87 Master Annular Sensor "like for like" due to malfunction. Proper operation of the <br /> new sensor was confirmed. <br /> Replaced Tank 87 Syphon Annular Sensor"like for like" due to malfunction. Proper operation of the <br /> new sensor was confirmed. <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 't n 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 />