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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) This form must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy 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 agency regulating the USTs within 30 days of the date of the monitoring system certification. I . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10181059 8/6/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Quick Stop # 138 Business Site Address City ZIP Code 1153 Lincoln Blvd Tracy IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Walton Engineering , Inc . ( 916 ) 372 - 1888 Mailing Address P . O . Box 1025 , West Sacramento , CA 95691 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Curtis Carpenter Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 8167865 5/ 13/2020 Monitoring S stem Training and Certifications List all ap licable certifications. Expiration Date Veeder- Root 12/4/2020 Va orless - VMI 2/4/2021 111 . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA Q Monitoring System Set-up Alarm History Report Was any monitoring equipment replaced ? El0 11 (If Yes identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) Was damage , debris , or liquid found inside any secondary containment systems? j (If "Yes, " describe what was found in section IV below) Is all monitoring equipment operational per manufacturer's specifications? NX El El (If "No, " describe why in section IV below) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. , I A small amount of water was removed from all three STP sumps . �a IENV ROWE F3 A 91 EN is V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16, Section 2638 and all information contained herein is true and accurate . Attached to this certification is information (e. g . , manufacturerschecklists , monitoring system set-up, alarm history report, etc .) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature I CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable I' i