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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy of this form <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this formto the local agency regulating the <br /> 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 /> 10181886 01104/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> VALLEY PACIFIC LODI PLANT&CAR DLOCK <br /> Business site Atldress City 3Code <br /> 931 EVictor Ave. Lodi 95240 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing One Certification Phos# <br /> CGRS (916) 991 - 1100 <br /> lmailing Address <br /> 5444 Dry Creek Road; Sacramento, Ca. 95838 <br /> Nara of UST ServiceTechnician Pertomning the Certific wn(PrIW as shown om the ICC CerbfloafMn) <br /> Garrett Warren <br /> ContieciorRonk Testa licence# ICC Certification# ICC Certification Enpiraion Date <br /> CSLB#803616 SWRB#06-1672 8185019 10-2-2019 <br /> Monitoring ern Traa arM Certificatiara Llat all Ilcabb cert#kvtlons -ration Dae <br /> 842126 Veec erroci 1-23-2019 <br /> VMI LDT-890 Tester/#3822 438-2020 <br /> III. RESULTS OF TESTING/SERVICING <br /> Ind/tate and adach Me fiNlowlog reports if the monihxing equipment is capable of generating either. <br /> E Monitoring System Set-up EI Alarm History Report Y N NA <br /> Was any monitoring equipment replaced? <br /> (#^Yes,^identify Me specific devices replaced and list Me manufacturer and modelfor all replacement parts in section W El E3 0 <br /> below <br /> Was damage,debris, or liquid lound inside any secondary containment systems? 0 0' 0 <br /> (#^Yes^describe whatwas found in section W below.) <br /> Isalmoatorirg equipment operational per manufacturer's specifications? El 0 O <br /> (#^No-describe why in section IV below.) <br /> IV. COMMENTS <br /> Ifdlrecled b use this section,descnbe how and when Me issues were or will be comected. <br /> The LD 2DDD on the T7:UNLD tank failed and was replaced like for like with a new LD 2DDD.Tested and passed, <br /> OLD Serial number is D7D3141 D. NEW Serial number is 181 D1 6D9, <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 ver?fy that this information and the site plain shoseling the layout of UST s tem is complete and accurate. <br /> UST service Technician signature <br /> CERS=CafonYa Fmircrrrvr[al Reporting System ID=klerdficatbm ICC a International Code Caaci4 Y=Yes,N=No,NA=Not g3oicable <br />