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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> FThIsform must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy <br /> m must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> ulatin 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 /> 10180519 8/28/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) ui ng # <br /> Shell #68150 <br /> Business Site Address ZIP Code <br /> 13975 E . Hwy 88 195237 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems , Inc, �® (408) 971 -2445 <br /> Mailing Address <br /> 680 Quinn Ave. , San Jose 95112 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Brian McPheely <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /7/2019 <br /> Monitorinq S stem Training and Certifications List all applicable certifications. Expiration Date <br /> VR B36745 2/27/2020 <br /> VMI 12/7/2019 <br /> 1110 RESULTS OF TESTING I SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. YnNNA <br /> Monitorin S stem Set-u Alarm Histo Re ort <br /> Was any monitoring equipment replaced ? El Z El <br /> (if "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts In section 1V below) <br /> Was damage , debris , or liquid found inside any secondary containment systems? F 0 <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 insection IV below.) _ <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> RECEP E D <br /> [ P ! o 41 q <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 1 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 = Cali omla Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N ~ No, NA = NotAopricable <br />