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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 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 10180893 4/ 16/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Quik Stop Market # 132 Business Site Address City ZIP Code 3555 W Hammer Lane Stockton 195219 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Walton Engineering , Inc . ( 916 ) 372 - 1888 Mailing Address P . O . Box 1025 , West Sacramento , CA 95691 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Anthony Reyes Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 8293772 9/ 16/2020 Monitoring System Training and Certifications List all applicable certifications. Ex iration Date Veeder Root Level 4 # 1345115 2/ 13/2019 Bravo SWAT VMI Leak detection #3752 7/ 12/2019 Ili . RESULTS OF TESTING I SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA 0 Monitoring System Set-up ❑X Alarm History Report Was any monitoring equipment replaced? ❑ (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? ❑ 0 ❑ (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer' s specifications ? ❑X ❑ ❑ (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. Removed a small amount of liquid from all udc's 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 Am r;� I�� CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Coundl, Y = Yes, N = No, NA = Not Applicable