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CERS=California Environmental Report <br />UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br />This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A <br />copy of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form <br />the local agency regulating the USTs within 30 days of the date of the monitoring system certification. <br />to <br />la FACILITY INFORMATION <br />CERS ID <br />10181341 <br />Date of Monitoring System Certification <br />1 11/15/2018 <br />&nbspBusiness Name (Same as Facility Name or DBA-Doing Business As.) <br />CHEVRON #99840 (N31) <br />Building # <br />Business Site Address <br />4344 E WATERLOO RD @ 99 <br />City: <br />STOCKTON <br />Zip: <br />95215 <br />II. UNDERGROUND STORAGE TANK <br />SERVICE TECHNICIAN <br />INFORMATION <br />Name of Company Performing the Certification <br />TANKNOLOGY INC. <br />Phone # <br />(800) 800-4633 Ext. <br />Mailing Address <br />11000 N. Mopac Expressway #500, Austin, TX 78759 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br />Jarrod Cooke <br />Contractor/Tank Tester License # <br />Class A General Engineering 743160 <br />ICC Certification # <br />5311523-UT <br />ICC Certification Expiration Date <br />4/6/2019 <br />Monitoring System Training and Certifications List all applicable certifications.) <br />Expiration Date <br />Tanknology Certification Level III ATG Operability Training Certification Exam 33235 <br />03/02/2020 <br />Veeder Root VR Level 4 B35255 <br />04/17/2020 <br />III. RESULTS OF TESTING/SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />ry 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 parts in section IV below.) <br />r <br />170 <br />r <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />(If "Yes, " describe what was found in section IV below.) <br />r <br />r <br />r <br />Is all monitoring equipment operational per manufacturer's specifications? <br />(If "No," describe why in section IV below.) <br />IVX COMMENTS <br />If directed to use this section, describe how and when the issues were or will be corrected. <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 <br />to this certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) <br />necessary 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 />ing System, ID=Identification, UST=Underground storage tank, ICC=International Code Council <br />