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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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10156809 1 /22/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) T Building # <br /> Safeway <br /> Business Site Address City ZIP Code <br /> 2802 Country Club blvd Stockton 95204 <br /> 11 . 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 Date <br /> 485184 8822062 11 /9/2019 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> VR B36745 2/27/2020 <br /> VMI 11 /29/2019 <br /> Ilia RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports If the monitoring equipment is capable of generating either. y N NA <br /> ® <br /> Monitoring System Set- up ® Alarm History Report <br /> Was any monitoring equipment replaced? 0 El <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? <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer' s specifications? © El F <br /> (If "No, " describe why in section IV below.) <br /> IV. COMMENTS <br /> if directed to use this section, describe how and when the issues were or will be corrected. <br /> Replaced the Diesel Fill Sump Sensor (VR 794380-208) - Retested & Passed. <br /> R rMg <br /> LH 6 2019 <br /> LENTA&- HEALTH <br /> ENVIRONME <br /> D €T '^' l IT 9�1 inn E) k <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> hereby certify that the equipment identified in this document was inspected/serviced 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 = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br />