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19020&011 <br /> 4 <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 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 /> agency regulating the USTs within 30 days of the date of the monitoring system certification . <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 04/ 12/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Lodi CA FO Term (Intl) I LODICA <br /> Business Site Address City ZIP Code <br /> 2500 West Turner Road Lodi 195242 <br /> li . 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 /> Spencer Kissick <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 703190 8169987 1 / 10/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Ex iration Date <br /> Franklin Fueling 41749 <br /> Vaporless 344-2021 <br /> III . RESULTS OF TESTING / 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? 0 El F1 <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? <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 <br /> CERS = Califomh Environmental Reporting System, ID = Identification, ICC = Intemationai Code Council, Y = Yes, N = No, NA = Not Applicable <br /> QA/QC APPROVED <br /> 6/5/20193 :49 PMMegan Rodr <br />