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UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (Pagel 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 />I. FACILITY INFORMATION <br />CERS ID <br />10180831 <br />Date of Monitoring System Certification <br />8/31/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />STOP N SHOP <br />Building # <br />Business Site Address <br />1856 COUNTRY CLUB <br />City <br />�STOCKTOKCA <br />ZIP Code <br />95204 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />AFFORDA TEST <br />Phone # <br />(209) 744-0112 <br />Mailing Address <br />416 2ND STREET GALT, CA 95632 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />DAVID WINKLER <br />Contractor / Tank Tester License # <br />08-1739 Ex. 3/31/23 <br />ICC Certification # <br />8883059 -UT <br />ICC Certification Expiration Date <br />1/27/2022 <br />Monitoring System Training and Certifications List all applicable certifications. Ex iration Date <br />Veeder Root B34975 2/7/2022 <br />Incon 1009853708 11/30/2020 <br />III. RESULTS OF TESTING I SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />X❑ Monitoring System Set-up ❑X Alarm History Report <br />Y <br />N <br />NA <br />Was any monitoring equipment replaced? <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? <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 />V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />I 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 />