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RECEIVED VIA EMAIL ON 04-11-2022 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 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 /> allen,,y regulating 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 /> 10180759 4/18/19 Ifl <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> Mobil#68222 <br /> Business Site Address City ZIP Code <br /> 2132 Mariposa Rd. I Stockton 95205 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Service Station Systems (408)971-2445 <br /> Mailing Address <br /> 680 Quinn ave San Jose Ca, 95112 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> Brian McPheely <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8822062 11/9/2019 <br /> Monitoring System Training and Certifications List all applicable certifications.2 Ex iration Date <br /> VR B36745 2/27/2020 <br /> VMI 11/29/2019 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Monitoring System Set-up Alarm Histo[y Report <br /> Was any monitoring equipment replaced? © 11 <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? z 1:1 El <br /> (If"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? Z El ❑ <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 /> Replaced External Overfill Acknowledgment Button Box-Tested&Passed. <br /> Removed Liquid from 89 Fill Sump. <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 la out 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 />