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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Paye 4 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 /> 1. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 12/13/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Arco 7049 <br /> Business Site Address City ZIP Code <br /> 800 E Kettleman Lodi 195240 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> r <br /> er Ryan Inc (925 ) 551 -4777 <br /> g Address Sierra Ct . Dublin , CA 94568 <br /> of UST Service Technician Performing the Certification (Print as shown on the ICC Cerii>lcation) <br /> d Rouse <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 6/4/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root TLS3XXX technician 844848 7/2/2020 <br /> VMI Line Leak #3625 9/7/2020 <br /> VMI LDT-890 Leak Detector Tester #3626 9/7/2020 <br /> Ili . RESULTS OF TESTING 1 SERVICING <br /> indicate and attach the following reports ff the monitoring equipment is capable of generating either. y N NA <br /> x Monitoring System Set-up x Alarm HistoEy Report <br /> Was any monitoring equipment replaced? <br /> pt "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts In section 1V below.) <br /> Was damage, debris, or liquid found inside any secondary containment systems? <br /> (11 "Yes, " describe what was found In section 1V below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? Q 0 <br /> (ll 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 /> i { <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspectediserviced 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 Iay2 g of UST system is complete and accurate , <br /> UST Service Technician Signature <br /> CERS = CaVomia Envitonmerfal Reporting System, ID = /der fication. ICC = hrternationai Code Council, Y = Yes, N = No, NA = Not Applicable <br />