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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 equip rrAoy form <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the Iola ageriby' a aif' g the <br /> USTs within 30 days of the date of the monitoring system certification. <br /> _ I . FACILITY INFORMATION HZONM " ' <br /> CERS ID Date of Monitorihvwgw tMilicati6n <br /> 7/03/2020 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> Lodi 76 <br /> Business Site Address City ZIP Code <br /> 141 E Harney In Lodi 19524 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> MVP Petroleum Eng Inc ( 916) 205 - 1537 Ext . <br /> Mailing Address <br /> P . O . Box 281 Folsom Ca 95763 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br /> Steven Jones <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 768938 6205 8/5/2021 <br /> monitoring S stem Training and Certifications List all applicable certifications. Expiration Date_ <br /> Veeder Root TLS-350 6/21 <br /> 111 . 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? ❑ ® ❑ <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.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ® ❑ ❑ <br /> (If Wo, " describe why in section 1V below.) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> LK <br /> Mh 10 q r nne)�' <br /> ds €J L J aur_,. .+ <br /> I, INVIR0Ni® 1L. NTA L IILt\ L1 lI <br /> 1 ) 14. PAIZ1 �-i 1ILN T <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 showin the layout of UST s stem is complete and accurate. <br /> UST Service Technician Signature <br /> F <br /> CERS = California Environmental Reporting System , ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not applicable <br /> E <br />