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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM PageI of 6) <br /> Fagency <br /> st be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy <br /> ust be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> atin the USTs within 30 days of the date of the monitoring system certification. <br /> L FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10180529 5/22/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> J & L MARKET <br /> Business Site Address City ZIP Code <br /> 8115 S . ELDORADO ST ISTOCKTONCA 95231 <br /> IL 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 ST . GALT , CA 95632 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the /CC 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. Ex iration Date <br /> Veeder Root A31048 6/3/2020 <br /> Incon 1009893708 11 /30/2020 <br /> III. RESULTS OF TESTING i SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> X <br /> Monitoring System Set-up X Alarm History Report <br /> Was any monitoring equipment replaced? El Q <br /> El <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 n ❑ <br /> (If "Yes, n describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? rl <br /> (If Wo, " 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 /> fa > . <br /> 1 <br /> [ � . ;`' fix €``� .¢° ® J -r° �. . <br /> � 1 ,/� <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 = California Environmental Reporting System, ID = Identification, ICC = Intemational Code Council, Y = Yes, N = No, NA = Not Applicable <br /> j <br />