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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page I 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 /> a enc re Matin the USTs within 30 da sof the date of the monitorin system certification . <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181399 5/30/ 19 <br /> Business Name (Same as Facility Name or DBA-ODing Business As) Building # <br /> Grantline Shell <br /> Business Site Address City ZIP Code <br /> 2375 W. Grant Line Tracy 95376 <br /> 11 . 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, Ca 95112 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the iCC Certification) <br /> Kristopher Bell <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8833000 7/22/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root 3/25/2021 <br /> V. M . I 10/31 /2020 <br /> 111. RESULTS OF TESTING 1 SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> ® <br /> 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 and model for all replacement parts in section 1V below.) <br /> Was damage , debris , or liquid found inside any secondary containment systems? <br /> (If "Yes, " describe what was found in section IV below.) El W1 1:1 <br /> Is all monitoring equipment operational per manufacturer' s specifications? <br /> (If "No, " describe why in section IV below.) 0 EJ <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> Nh <br /> E�wm llk7W�AY �M* <br /> Dr u � r-� € g �� �„e � <br /> PA � It/I E, N <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 = International Code Council, Y = Yes, N = No, NA = NotAppkable <br />