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tl UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page t of 6) This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy 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 agency regulating the USTs within 30 days of the date of the monitoring system certification . 1. FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10186995 11 /21 /2018 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Chevron Business Site Address City ZIP Code 1916 E . March Lane [Stockton 195210 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Nucleus Pump Services (916) 3824761 Mailing Address 601 1st Street , Suite B , Sacramento , CA 95818 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Chris Bishop Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 949066 82116429 5/2/2020 Monitoring System Training and Certifications List all geJeticable certifications. Expiration Date Veeder Root 6/ 19/2020 III . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA XD Monitoring System Set-up Alarm History Report Was any monitoring equipment replaced? 9 ❑ ❑ (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) Was damage , debris , or liquid found inside any secondary containment systems? (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? O (If "No, " describe why in section IV below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. THE 87 FILL SUMP SENSOR WAS NOT WORKING THE VEEDER ROOT 208 WAS REPLACED LIKE FOR LIKE AND RETESTED AND PASSED , S-5 WAS X, ED OUT OF PROGRAMING THE S-5 IS THE DIESEL/91 TANK ANNULAR AFTER PUTTING THE S-5 VAC SENSOR BACK IN PROGRAMING THE SENSOR WORKED AND PASSED TESTING MADE REPAIRS TO VAC HOSE AND THE S-5 WAS HOLDING VACUUM AS WELL , I REMOVED LIQUID FROM THE DIESEL STP SUMP AGOUT 1 GAL , UDC 9- 10 REMOVED FUEL ABOUT 2 GAL. , UDC 11 - 12 REMOVED ABOUT 1 GAL . , UDC 9- 10 FOUND THAT DIESEL METER END PLATE HAS A SMALL DRIP UDC 9-10 WAS CALLED IN FOR REPAIRS . . THE S3 VAC LIQUID SENSOR FAILED THE LIQUID TEST, 11 /28/2018 RETURNED WITH THE S3 LIQUID SENSOR AND REPLACED AND RETESTED THE S-3 LIQUID SENSOR PASSED ALL OK . V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations , Title 23, Division 3, Chapter 16 , Section 2638 and all information contained herein is true and accurate. Attached to this certification is information (e.g . , m nufacturers' checklists , monitoring system set-up, alastory , report, ete } ,necessaiy to verifythat this information and the e Ian showingthe layout of UST s stem is com le'te ai eurkte = i UST Service Technician Signature APi ,. 17 1 7010 CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable V1Rl t\! 1VI ' iN� teli. r ErYEk µ i i €-