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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> illilllllllllll :1 1 <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 /> 10181447 6/ 12/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Mobil # 68154 <br /> Business Site Address City ZIP Code <br /> 2500 W Lodi Lodi 195242 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems (408 ) 971 -2445 <br /> Mailing Address <br /> 680 Quinn Ave . San Jose , Ca 95112 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Kristopher Bell <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 18833000 7/22/2020 <br /> Monitoring System Train! ig and Certifications List all applicable certifications.) Expiration Date <br /> Veeder Root 3/25/2021 <br /> V. M . I 10/31 /2020 <br /> III . RESULTS OF TESTING 1 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 Histonj 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? El ® El <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 /> LKLO Lo <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> EIV E <br /> JUN 2 1 2019 <br /> ENVIRONNIENIEAL HEALTH <br /> DEPARTINIENT <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 layout of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br />