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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM <br /> I . FACILITY INFORMATION <br /> CERS ID Date : <br /> 10/ 17/2018 <br /> Business Name Building # <br /> Sunwest Chevron <br /> Business Site Address City Zip Code <br /> 2758 W Kettleman Ln Lodi <br /> II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing Test Phone # : <br /> BZ Service Station Maintenance 916-371-2380 <br /> Business Mailing Address <br /> 1401 Triangle Ct ., West Sacramento, CA 95691 <br /> Name of UST Service Technician <br /> Darnell Smith <br /> Contractor License # : 433159 ICC Certification # : 8709494 ICC Certification Expiration Date : 12/21/2019 <br /> Monitoring System Training & Certification Expiration Date <br /> Veeder Root TLS 3xx- B48857 3/29/2020 <br /> III , RESULTS OF TESTING / SERVICING <br /> Indicate & attach the following reports if the monitoring equipment is capable of generating either. Y N N /A <br /> E Monitoring System Set-up ® Alarm History Report <br /> Was any monitoring equipment replaced ? <br /> ( if "Yes" identify the specific devices replaced and list the manufacturer & model for all replacement parts in section IV ® 0 ❑ <br /> Below ) <br /> Was damage, debris, or liquid found inside any secondary containment systems ? ❑ E ❑ <br /> ( If "Yes" describe what was found in section IV below . ) <br /> Is all monitoring equipment operational per manufacturer' s specifications? E ❑ ❑ <br /> ( If " No" describe why in section IV below . ) <br /> IV . COMMENTS <br /> Describe how and when the issues were or will be corrected . <br /> 10/ 17/2018- Need to return to replace & retest failed DSL Spill Bucket ( EMCO spill bucket 5 gallons . <br /> 12/27/2018m Replaced , Tested & PASSED DSL Spill Bucket w/ Elite IV. _ <br /> REGEN <br /> NOV P 4 2019 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> V . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hearby certify that the equipment identified in this document was inspected/serviced in accordance with California Regulations , Title 23, Division <br /> 3, Chapter 16, Section 2638 and all information contained herein is true and accurate . Attached to this certification is information ( e . g . <br /> manufacturers' checklists, monitoring system set- up, alarm history report etc . ) necessary to verify that this information and the site plan showing <br /> the layout of UST system is complete and accurate. <br /> UST Technician Signature <br />