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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy 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 agency re ulatin the USTs within 30 days of the date of the monitoring system certification . I . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10181461 6/26/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Vanco Truck and Auto Plaza Business Site Address City ZIP Code 1033 W Charter Way I Stockton 195206 ll . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Elite IV Contractors ( 209 ) 461 -6337 Mailing Address 2535 Wigwam Dr Stockton Ca 95205 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Chris Adams Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 8230218 4/ 17/2020 Monitoring System Training and Certifications List all applicable certifications. Expiration Date III . RESULTS OF TESTING I SERVICING Indicate and attach the following reports If the monitoring equipment is capable of generating either. Y N NA XQ Monitoring System Set-up Alarm History Report Was any monitoring equipment replaced? ❑ El Q (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below) Was damage , debris, or liquid found inside any secondary containment systems? El a (if "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? (If "No, " describe why in section IV below.) " Iva `COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. VMI mechanical LD VMI 2000 New SN# 19011089 JUN 23 7 01 ) ENVIRONMENTAL HEALTl 1 DEPARTMIENT U. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations, Title 23 , Division 3 , Chapter 16 , Section 2638 and all information contained herein is true and accurate. Attached to this certificatio q i format' n (e. g . , manufacturers' checklists , monitoring system set-up, alarm history report, etc .) necessary to verifythat t rs i rmati and the site plan showing the layout of LIST system is complete and accurate. UST Service Te hnici n !gnat re I i CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable i