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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM <br /> I . FACILITY INFORMATION <br /> CERSID Date : <br /> 11/ 18/2019 <br /> Business Name Building # <br /> 76 March Lane <br /> Business Site Address City Zip Code <br /> 1916 March Lane Stockton <br /> II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing Test Phone # : <br /> BZ Service Station Maintenance 916-371-2380 <br /> Business Mailing Address <br /> 1401 Triangle Ct ., West Sacramento, CA 95691 <br /> Name of UST Service Technician <br /> Rhome Desbiens <br /> Contractor License # : 433159 ICC Certification # : 524434- UT ICC Certification Expiration Date : 1/4/2021 <br /> Monitoring System Training & Certification Expiration Date <br /> VeederRoot- A22883 2/27/2021 <br /> VMI LD Tester- 2906 7/8/2020 <br /> III , RESULTS OF TESTING / SERVICING <br /> Indicate & attach the following reports if the monitoring equipment is capable of generating either. Y N N /A <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 & model for all replacement parts in section IV ❑ ® ❑ <br /> 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 <br /> Is all monitoring equipment operational per manufacturer's specifications? El <br /> ( If "No" describe why in section IV below. ) <br /> IV. COMMENTS <br /> Describe how and when the issues were or will be corrected . <br /> Unable to test L18 (87 Fill Brine) sensor. (Stuck in alarm ) (Open work order for L18 repair. ) Will test L18 after repairs. <br /> Pumped small amount of water from DSL STP Sump <br /> V . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hearby certify that the equipment identified in this document was inspected/serviced in accordance with California Regulations . Title 23, Division <br /> 3, Chapter 16, Section 2638 and all information contained herein is true and accurate . Attached to this certification is information ( e. g . <br /> manufacturers' checklists, monitoring system set- up, alarm history report etc . ) necessary to verify that this information and the site plan showing <br /> the layout of UST system is complete and accurate . <br /> UST Technician Signature <br /> i <br /> i <br /> i <br /> i <br />