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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (page 9 of B} of this form <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment A copy <br /> 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 <br /> USTs within 30 days of the date of the monitoring system certification, <br /> FACILITY INFORMATION <br /> CERS ID hate of Monitorin System Cert cation <br /> �p1-51123 <br /> Business Na0e(Same as Facility Name or D —0,Ding Business As.) Buitding# <br /> S r CC_l City ZIP Code <br /> Business Si Address l-I 4a <br /> „/o ��� STOC- �F�., <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Jauregui &Culver inc. (760) 743- 0518 EXL <br /> Maiiing Address <br /> 959 W.Mission ave. Escondido, Ca 92025 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the JCC Certification) <br /> Peter Jauregui Ill <br /> Contractor/Tank Tester License# ICC Certification# L6-:2-19 <br /> ertifica#ion Expiration Rate <br /> 708231 8195227 <br /> MonitoringSystem Trainin and Certifications C ist air a licable certiticatiuns. iration gate <br /> Veeder-Root B34641 � <br /> Ill. RESULTS OF TESTINGISERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable ofgenerating either. Y N NA <br /> Monitoring System Set-up Alanm History Report <br /> Was any monitoring equipment replaced? ❑ <br /> (if-'es,-idengry the specific devices replaced and list the manufacturer and model for all replacement parts in section W below) <br /> Was damage,debris,or liquid found inside any secondary containment systems? ❑ ❑ <br /> (ff"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's spedificatiorts? ❑ <br /> (if'No,"describe why in section IV below.) <br /> IV_ COMMENTS <br /> If directed to use this section, describe now 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 inspectedlserviced in accordance with Californ7CodeofRegulations,title 23, division 3,chapter'16,section 2638 and all information contained herein is true and accuratethis certification is information(e.g.,manufacturers`checklists, monitoring system set-up,alarm history report,et <br /> to verif that this informati nd the ie Ian showingthe layout of UST system is complete and accurate. <br /> UST Service Technician Sig <br /> CFR$C Ca]ifonua Fnvirorunental Reporting System,ID=Identification,ICC=International Code Council,Y=Yes,N=No,NA=Not applicable <br />