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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 /> CER5 ID Date of Monitoring System Certiflcation <br /> 10187387 8/29119 <br /> g <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Buil in # <br /> Valero BP 29 <br /> Business Site Address City ZIP Code <br /> 1137 W Lathrop Rd . Manteca 95, <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems (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 /> Brian McPheely <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration;2/27/ <br /> 485184 8822062 11 /9/2019 <br /> MonitoringSystem Trainin and Certifications List all applicable certifications. iration Date <br /> VR 636745 020 <br /> VMI <br /> 11 /2912019 <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 Histo 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 IV below.) <br /> Was damage, debris , or liquid found inside any secondary containment systems? El1:1 <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer' s specifications? [7� ❑ ❑ <br /> (if "No) " describe why in section 1V below.) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> During Brine Communication Testing Plug Broke , Replaced & Installed Test Apparatus , May Need to Top Off Brine after Sump Burps . <br /> fA <br /> R r%vavy �n.?f <br /> SEP 2 4 201 <br /> ENVIRONMENTAL= HC_AE " N <br /> DEPARTMENT <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspectediserviced 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 = Identificat on, ICC = Intemational Code Council, Y = Yes, N = No, NA = Not Applicable <br />