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190215 -563 <br /> UNDERGROUND STORAGE 'TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> Fagency <br /> st be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy <br /> ust be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> tin the USTs within 30 days of the date of the monitoring system certification . <br /> Is FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10403278 03/25/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Lodi CA FO Term (Intl) LODICA <br /> Business Site Address City ZIP Code <br /> 2500 West Turner Road Lodi 95242 <br /> Il . ` ' UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the. Certification Phone # <br /> SunWest Engineering Const. , Inc. (888) 588-8737 <br /> Mailing Address <br /> 4780 Cheyenne Way, Chino, CA 91710 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Kraig Kinder <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 703190 8296393 12/7/20 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Pnumercator 11 /9/ 19 <br /> III . RESULTS OF TESTING l SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> ® Monitoring System Set-up ® Alarm History Report <br /> Was any monitoring equipment replaced? n <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 <br /> (If "Yes, " describe what was found In section IV below.) <br /> Is all monitoring equipment operational per manufacturer' s specifications? <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 /> 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 Digitally signed by Kraig Kinder <br /> Kraig Kinder Date : 2019 .03.2514 :05: 15 -07'00' <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = NotApplicable <br /> QA/QC APPROVED <br /> 3/27/201911 : 34 AMTeresa An <br />