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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page I of 6) <br /> ank (UST) <br /> ment. A <br /> py <br /> This form must used v d d t the UST owner or operator. The owner or operator tmonitoring <br /> to document testing and servicing ot underground s or <br /> ormust submit a copy of hisform to theolocal <br /> of this form mustt be pro <br /> agency regulating the USTs within 30 days of the date of the monitoring FACILITY INFORMATIONtemcertifica ion . <br /> Date of Monitoring System Certification <br /> CERS ID 5/22/2020 <br /> 10180657 Building # <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> CENTRAL GAS city zIP Code <br /> Business Site Address STOCKTON , CA 95202 <br /> 642 N . HUNTER STREET <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIANINFORMATION <br /> Pho <br /> Name of Company Performing the Certification (209 ) 744- 0112 <br /> AFFORDA TEST <br /> Mailing Address <br /> 416 2ND ST GALT , CA 95632 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> ZANE NIMMO ICC Certification Expiration Date <br /> ICC Certification # 6/ 1 /2021 <br /> Contractor / Tank Tester License 3064- UT <br /> 04 - 1676 Ex . 3/31 /22 Ex iration Date <br /> Monitorin S stem Training and Certifications List all a licable certifications. 10 /2/2021 <br /> Veeder Root A28446 11 /30/2020 <br /> Incon1009843708 <br /> III . RESULTS OF TESTING I SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is cap Alarm Histo at'Re porter. <br /> 13 <br /> Y N NA <br /> ❑x Monitorin clinfnm -qpt-un 0 0 El <br /> Was any monitoring equipment replaced? <br /> " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below. <br /> (If "Yes, ❑ ❑ El damage , debris , or liquid found inside any secondary containment systems? <br /> (If "Yes, " describe what was found in section IV below.) xx ElIs all monitoring equipment operational per manufacturer's specifications? Li <br /> (If "No, " describe why in section IV below.) IV . COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> RECEIVE i L I) <br /> SEP 2020 <br /> ENVIRONMENTAL. HEALTH <br /> DEPARTNIFNT <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> s ill I hereby certify that the equipme dt1S Section 2638 andd in this nt weaall information contained herein is ldiserviced in accordance <br /> and accurate ,r Attached to <br /> Regulations , Title 23 , Division 3 , Chapter <br /> this certification is information <br /> and he site manufacturers <br /> rens chec <br /> ing the rlayout ofrUST system s complete aand arccurate poi' etc . necessary <br /> to verif that this int <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 />