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06 / 28 / 2019 19 : 29 8387674 EIr1ILS PAGE 19 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pa e1 of 61 <br /> This form moot be uaea to document testing and $ ervicing of underground storage tanK (V57 ) montcoring equip <br /> mont • /+ 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 /> a enc re ulatin the US7s within 30 da s of the date of the rr� onitorin s stem certification . <br /> I , FACILITY INFORMATION date of Monitoring System Certification <br /> EOIRDA <br /> 5/29/2019 <br /> 7 I Building # <br /> Businessame (Same as Facility Name or DBA- <br /> Poing Business As) I <br /> IQUOR AND SPORT SHOP Clry ZIP Code <br /> ite Address ESCALON , CA 95320 <br /> ILFORNIA STREET <br /> II . UNDERGROUND STORAGE TANK S !_ RVICE TECHNICIANtN `ORMATION <br /> mpany Performing the Certification (209 ) 744-0112 <br /> DA TEST <br /> Mailing Address <br /> 416 2ND ST GALT , CA 95632 <br /> Namo of UST Service Techntclan Performing the Certiflcslion (onnt as shown on thG /CC Ccirfi(iCafion) <br /> III <br /> FELIX RAMIREZ m <br /> ICC Certification # ICC ertification Expiration Date <br /> Conlredor / Tank Tester License # 88 $ 3072 - UT 11 /9/2020 <br /> 08 - 1740 EX . 3/31 /20 M77/77 <br /> ilon Da <br /> rIncon <br /> t rin S st m Trair and Certifications (List all ePplicaote esrtifiC�tlons } /2020 <br /> 41 <br /> der Root B34976 0/2020 <br /> 1009883708 <br /> 111 . RESULTS OF TESTING / SERVICING _ <br /> Indicate and atiach the following reports if the monitoring equipment is capable of generating either. y I N NA <br /> x Monitolin System Set-UPxC' Alarm Histo Re ort <br /> Was any monitoring equipment replaced ? I 0 <br /> (If °Yes, " identify the specific devices replaced and list the manufscturorand model for all replacement parts in section IV below.) <br /> �I ' ❑ El damage , debris, or liquid found inside any secondary containment0 <br /> systems? <br /> (It "Yea, " dc3oribe what Was found in section IV below.) i ❑ <br /> Ox <br /> Is ail monitoring equipment operational per manufacturers specifications ? <br /> (If III describe why in section IV Wow.) <br /> Iv. COMMENTS <br /> It directed to use thla section, describo 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 inspectediserviced in accordance with callfornia Code of <br /> Regulations , Title 233 Division 3 , Chapter 16, section 2638 and an 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.. showina the layout of UST system Is complete and accurate, _ <br /> UST Service Technician Signature ?Jr <br /> CERS = Caltomle Environmental Rcpating System, ID = Identification. ICC = Intemational Code Council, Y = Yes, N = No, NA = Not Applicable <br /> Received Time Jun , 28 . 2019 7127PM No , 5223 <br />