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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> !Iiiiiii: OEM! iiiliiiiiiiiii WINES <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 /> 10411900 5/7/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Shell # 68221 <br /> Business Site Address City _ ZIP Code <br /> 2705 Country Club Stockton 195204 <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 it Certification) <br /> Kristopher Bell <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8833000 7/22/2020 <br /> Mraining and Certifications List all applicable certifications. ) Expiration Date <br /> Veeder Root 3/25/2021 <br /> V. M . I 10/31 /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 /> (� <br /> Monitorinq 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) <br /> Was damage , debris, or liquid found inside any secondary containment systems? <br /> (if "Yes, " describe what was found in section IV below.) El FA El <br /> Is all monitoring equipment operational per manufacturer's specifications ? <br /> (if %Jo, " describe why in section IV below) Z El <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> V <br /> p <br /> t <br /> i <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 verifV 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, [CC = International Code Council, Y = Yes, N = No, NA = NotApplicable <br />