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UNDERGROUND STORAGE TANK <br />CERS = Cafifomia Environmental Reporting System, ID = Identification, ICC =International Code Council, <br />MONITORING SYSTEM CERTIFICATION FORM (Page l 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 form to the local <br />agency regulating the USTs within 30 days of the date of the monitoring s stem certification. <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Monitoring System Certification <br />3/8/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As) Building # <br />Chevron CSI <br />Business Site Address city ZIP Code <br />6633 Pacific Ave. Stockton CA 195207 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification Phone # <br />Nucleus Pump Services (916) 3824761 <br />Mailing Address <br />601 1st Ave, Suite B, Sacramento, CA 95818 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />Brian Roth <br />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />949066 8834817 10/19/2019 <br />Monitoring System Training and Certifications List all applicable certifications,l <br />Expiration Date <br />Veeder Root <br />10/29/2019 <br />III. RESULTS OF TESTING I SERVICING <br />Indicate and attach the following reports If the monitoring equipment is capable of generating either. <br />❑X Monitoring System Set-up Alarm History Report <br />Y <br />N <br />NA <br />Was any monitoring equipment replaced? <br />(If "Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement pans in section lV below.) <br />❑ <br />Q <br />❑ <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />"Yes, " describe <br />1:1 <br />nX <br />El <br />(If what was found in section IV below.) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />(If "No,"describe why in section IV below) <br />FX <br />n <br />IV. COMMENTS <br />If directed to use this section, describe how and when the issues were or will be corrected. <br />R E <br />tAPR 1 1 2010 <br />ENVIRONMENTAL -1EALT <br />DEPART IVIENT <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 />Y = Yes, N = No, NA = Not Applicable <br />