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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page i of 6) This form must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy 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 agency regulating the USTs within 30 days of the date of the monitoring system certification . I . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 1 /28/ 19 Business Name (Same as Facility Name or DBA-Doing Business As) Building # BEN HOLT ARCO 7 Business Site Address City ZIP Code 2908 BEN HOLT STOCKTON Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # AFFORDA TEST (209 ) 744-0112 Mailing Address 416 2ND ST . GALT , CA 95632 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) EDWARDS STEARNS Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 14 - 1760 Ex . 9/30/20 8883080- UT 11 /9/2020 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder Root A31048 6/3/2020 Incon 1009893708 11 /30/2020 III . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA QX Monitoring System Set-up Alarm History Report Was any monitoring equipment replaced? El ❑X 0 (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below) Was damage , debris , or liquid found inside any secondary containment systems? ❑X n (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? F1 R (If No, " describe why in section IV below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. ilk Em= � < Y . i IIAR I. M �1 I I E NV I RO N 141 NTA ' V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations , Title 23 , Division 3, Chapter 16 , Section 2638 and all information contained herein is true and accurate , Attached to this certification is information (e. g . , manufacturers' checklists , monitoring system set-up , alarm history report, etc . ) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate , UST Service Technician Signature CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Coundl, Y = Yes, N = No, NA = Not Applicable i