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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 /> I. <br /> CEID FACILITY INFORMATION <br /> RS <br /> Date of Monitoring System Certification <br /> Business Name(Same as Facility Name or DBA-Doing Business As) ng#10/1/2019 <br /> Chevron Building# <br /> Business Site Address <br /> 8660 Lower Sac. RD, city T95210 <br /> IP Code <br /> Stockton Ca. <br /> II. <br /> Name of Company PeUNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> rforming the Certification <br /> Nucleus Pump Services Phone# <br /> Mailing Address <br /> (916) 382-4761 <br /> 601 1 St Ave, Suite B, Sacramento, CA 95818 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> Brian Roth <br /> Contractor/Tank Tester License# F1CC­C`e`rti_fi-ication# <br /> ICC Certification Expiration Date <br /> 949066 8834817 10/19/2019 <br /> MonitoringSystem Trainingand Certifications List all applicable certifications. <br /> Veederroot Ex iration Date <br /> 11/29/2019 <br /> III. RESULTS OF TESTING I SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> ❑X Monitoring System Set-up ❑X Alarm History Report Y N NA <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 lV below.) ❑ ❑ <br /> Was damage, debris, or liquid found inside any secondary containment systems? <br /> (If"Yes,"describe what was found in section IV below.) ❑ X❑ ❑ <br /> Is all monitoring equipment operational per manufacturer's specifications? <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 /> 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 /> CERS=Califomia Environmental Reporting System,ID=Identification,ICC=Intemational Code Council,Y=Yes,N=No,NA=Not Applicable <br />