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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. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10180779 8/25/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> MIRACLE MILE MARKET <br /> Business Site Address City ZIP Code <br /> 244 W. HARDING WAY �STOCKTOKCA 95204 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> AFFORDA TEST (209) 744-0112 <br /> Mailing Address <br /> 416 2ND STREET GALT, CA 95632 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> EDWARD STEARNS <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 14-1760 Ex. 9/30/20 8883080-UT 11/9/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A31048 7/31/2021 <br /> Incon 1009893708 11/30/2020 <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 /> ❑X Monitoring System Set-up ❑X 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 X El <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=International Code Council,Y=Yes,N=No,NA=Not Applicable <br />