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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel 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 system certification . <br /> I . FACILITY INFORMATION <br /> CERS ID Date R Monitoring System Certification <br /> 10180519 8/27/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Speedway 1486 <br /> Business Site Address City ZIP Code <br /> 13975 E . Hwy 88 Lockeford 95237 <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 /1 /2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root TLS 3XX B36745 11 /21 /2021 <br /> Vaporless Manufacturing Inc #3803 10/29/2021 <br /> Red Jacket #836745 10/29/2021 <br /> FE PETRO # 1014303708 11 /21 /2021 <br /> Ill . RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Q Monitoring System Set-up © Alarm History Report <br /> Was any monitoring equipment replaced? R © 0 <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 F✓ 0 <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? © ❑ El <br /> (if "No. " 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 /> RECEIVED <br /> I <br /> SEP 0 3 &M <br /> i <br /> ENVIRONMEN I AL iHEALTH <br /> DEPARTI I FNT <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 /> = <br /> i <br />