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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page1 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 <br /> local 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 /> 10165857 9/5/2019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As .) Building # <br /> 7- ELEVEN # 19976 , MKT 2368 <br /> Business Site Address City : Zip : <br /> 1399 N . MAIN ST. @ NORTHGATE MANTECA 95336 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> TANKNOLOGY INC . (800) 8004633 Ext. <br /> Mailing Address <br /> 11000 N . Mopac Expressway #500, Austin , TX 78759 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification .) <br /> Jarrod Cooke <br /> Contractor/Tank Tester License # 75311523-UT <br /> C Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 4/3/2021 <br /> Monitoring System Training and Certifications List all applicable certifications . ) Expiration Date <br /> Tanknology Certification Level III ATG Operability Training Certification Exam 33235 03/02/2020 <br /> ICC CA UST Service Technician 5311523- UT 04/03/2021 <br /> Veeder Root VR Level 4 835255 04/17/2020 <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 /> Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced ? r IV r <br /> (If 'Yes, "identify the specific devices replaced and list the manufacturer and model for alt 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.) <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 /> trace amount (Less than 1000 M ) Liquid pumped out of supreme fill sump . all passed . <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 <br /> to this certification is information (e . g . , manufacturers' checklists, monitoring system set-up, alarm history report, etc. ) <br /> necessary 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=California Environmental Reporting System , ID=Identification, UST=Underground storage tank, ICC=International Code Council <br />