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CERS = California Environmental Reporting System, ID =Identification, ICC = Internati UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy 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 agency regulating the USTs within 30 days of the date of the monitoring system certification. I. FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10180943 2/5/2019 Business Name (Same as Facility Name or DBA -Doing Business As) Building # SHOP N GO Business Site Address City ZIP Code 4511 PACIFIC AVE STOCKTON, CA 195207 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # AFFORDA TEST (209) 744-0112 Mailing Address 416 2ND ST. GALT, CA 95632 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) DAVID WINKLER Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 08-1739 Ex. 3/31/20 8883059 -UT 1/29/2020 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder Root B34975 2/8/2020 Incon 1009853708 11/30/2020 III. RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. ❑ Monitoring System Set-up ❑X Alarm History Report Y N NA Was any monitoring equipment replaced? ❑ ❑X (If " Yes, "identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) Was damage, debris, or liquid found inside any secondary containment systems? ❑ ❑X ❑ (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? ❑ ❑ (If "No. "describe why in section IV below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. RECEIV ED VAR 1 1 2019 ENVIRONMENTAL HEALTH DEPARTMENT V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, 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.) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature �i onal Code Counal, Y = Yes, N = No, NA =Not Applicable