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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM,(Page 1 Qf s) <br /> Fformst be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> atin the USTs within 30 days of the date of the monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181513 1/7/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> VDP - RIPON CFN <br /> Business Site Address City :]79753166 <br /> e <br /> 816 S FRONTAGE RD RIPON, CA <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> AFFORDA TEST (209) 744-0112 <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 /> EDWARD STEARNS <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 14-1760 Ex. 9/30/20 8883080-UT 11/9/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A31048 6/3/2020 <br /> Incon 1009893708 11/30/2020 <br /> ill. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> X Monitoring System Set-up XQ Alarm Histo Report N NA <br /> Was any monitoring equipment replaced? ❑ F-1(lf"Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section 1V below.) <br /> Was damage, debris,or liquid found inside any secondary containment systems? 0 <br /> (If"Yes,"describe what was found in section IV below.) El <br /> Is all monitoring equipment operational per manufacturer's specifications? F-1(if"No,"describe why in section iV below.) <br /> IV, COMMENTS <br /> if directed to use this section,describe Prow 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=Calffania Envirmnenial Reporting System,K)=Identificallon,[CC=International Code Council Y=Yes,N=No,NA=Not AppNcable <br />