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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page 1 of 6) This form must be used to document testing and servicing of underground storage tank ( LST) 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 LISTS within 30 days of the date of the monitoring system certification . I. FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10184805 10/16/19 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Rancho San Miguel Business Site Address City ZIP Code 610 Cherokee Lane Lodi 196240 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Service Station Systems , Inc. (408) 971 -2445 Mailing Address 680 Quinn Ave , San Jose 95112 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Raamon Frazier Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 485184 8020732 2/7/2019 Monitoring System Training and Certifications List all applicable certifications. Expiration Date VR 7/6/2019 VMI 12/7/2018 III . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA ® Monitoring System Set- up ® Alarm History Report Was any monitoring equipment replaced? (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? 0 7 F (/f "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications ? (If "Nor " 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. � 3 raj 1E N V IV i V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING 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 ., manufacturers' checklists , monitoring system set-up , alarm history report, etc . ) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature i CERS = Califomia Environmental Reporting System, ID = Identification, ICC = Intemational Code Coundl, Y = Yes, N = No, NA = Not Applicable