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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM This form must ba used to document tasting and servicing of underground stofsgp tank JUST -anitoring equipment A ropy of this faun 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 USTs within 30 days of the[tate of the monitoring system cilrtificatt�n I. FACILITY INFORMATION _ CERS IQ DgM of Monitoring System Certification 10180975 _ 13-25-20_19 Business Dame(Same as facddV Name or 08,4—Doing Brrsrnesa As.) I Buildings Stockton 76 13usrness Sita Addrrss CRY ZIP Code 8606 Thomton Rd. Stockton 95209 If. UNDERG R0_UNd STORAGE TANK SERVICE TECHNICIAN INFORMATION _ Norm of company Podorrning the Corsrfication ----- Phone s CGRS (916) 991 - 1100 Stalling Address T — 5444 Dry Creek Road: Sacramento, Ca. 95838 Name of UST Seance TechnPcsan Perforrmng the Certification(Prinf as shown an the ICC Cert+f+cahon.) — Garrett Warren ContravorrTank Tester Licensa t; ICC certifcation 8 ICC Connie tson Expiration Date CSLB#803616 8185019 10-2-2019 Monitorins SYstrm Training and Certifications(List ait AIRplitadle cert+Trcations.l Exp+rtt+oft Bate _ B42126 Veeder-root 1-21-21 VMI Lbf-890 Testerl#3822 4-30-2020 Ill. RESULTS OF TESTINGISERVICING IndMAI*and atractr u+r following reports rl the mono ring egwgpment is capable of generating tether. El Monitoring System Set-up El Alarm History Report Y N IIIA Was any monitoring equipment mplac,41_ T— (H"Yes,"identify the specific devices replaced and list the manufacturer and madel for air replacement parts in section IV ❑ 0 In beto w. Was damage,debris, or liquid found inside any secondary contairinnent systems . ❑ ❑ (ff"Yes,"describ e whit was found in section IVbelow.) Is all man nonng equIpmefit operational per manufacture:s spec itocittions7 ❑ .� ❑ Of"No,'describe why in saction IV billow.) IV. COMMENTS K directed to use this section.describe how and when the issues were Or will be corrected. The 87 and 91 spill bucket did not hold 5 gallons The 89 spill bucket failed and was leaking. The threads on the nipple are damaged. V. CEFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING RTI I hereby certify that the equipment identified in this document was inspectediserviced in accordance with Calilomia Code of Regulations,title 23,division 3,chapter 1£,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.)necessar, to verify that this Information and the site lass showin the la out of UST sYstem is complete and accurate. j UST Service Technician Signalura ^-_ 1 _ CERS=Cafifumia ErrvironnienMt Pop--rt,SysWtki.to=Idesi"cadon.1CC=InU-rnativ�ial Code Council Y=ti'es N 7 No.NA Not appicshic ODYSSEY APPS