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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (P*99 i of 6 <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 fort to the local <br /> agency regulating the USTs within 30 days of the date of the monitoring system certification. <br /> i. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10588471 8/9/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> SAN JOAQUiN GENERAL HOSPITAL ENG PLANT <br /> Business Site Address Ciry ZIP Code <br /> 500 W. HOSPITAL RD FRENCH CAMP , CA 95321 <br /> II . 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 STREET GALT , CA 95632 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the /Cc Certirication) <br /> EDWARD STEARNS <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 141760 Ex . 9/30/20 88830MUT 11 /9/2020 <br /> Monitorin SiiiemTralining and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A31048 Ed Stearns 6/3/2020 <br /> Incon 1009893708 Ed Steams 11 /30/2020 <br /> Sentinal Eric Mol card <br /> III. RESULTS OF TESTING I SERVICING <br /> Indicate and aftach the following reports ff 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 /> (K "Yes, " Idenfify the speck devices replaced and list the manufacturer and model for all replacement parts ir, 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 /> (N 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 /> Eric Molgaard Sentinial Certified = Bagley Enterprises on site <br /> RECEIVED <br /> AUG 2 3 2019 <br /> .ENVIRONMENTAL HEALTH <br /> DEPARTMENT <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 sat-up, alarm history report, etc.) necessary <br /> to verify that this Information and the site plan showing the layout of USTpyste-rn is complete and accurate. f <br /> UST Service Technician Signature ✓r` <br /> CERS an Caibrnia Envirorrnental Reporting System, ID = Identification, ICC = IniernaticrA Code Couna Y = Yes, N = No, NA = Nd Appkabie <br />