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, , <br /> UNDERGROUND STORAGE TANK A uh '> <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel of 6) qq I� <br /> This form must be used to document testing and servicing of underground storage tank (UST) monitoring equigt t1igor9f <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to tWe a n tl�e <br /> USTs within 30 days of the date of the monitoring system certification . DEPARTMENT <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10166191 05/26/20 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> Hammer I -5 Arco <br /> Business Site Address City ZIP Code <br /> 3201 W . Hammer Lane Stockton 95209 <br /> I1 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Alitech Petro , Inc . (209 ) 532 - 7320 Ext . <br /> Mailing Address <br /> P . O . Box 4208 Sonora Ca , 95370 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br /> Isaac Anderson <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CA 623541 /09- 1 749 8146912 06/ 12/20 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder- Root # 1336878 10/22/20 <br /> OPW # 100456 05/ 11 /22 <br /> 111 . RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> Y N NA <br /> ® Monitoring System Set-up ® Alarm History Report <br /> Was any monitoring equipment replaced ? [I M El <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? El ® EJ <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ® El D <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 /> i <br /> i <br /> i <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 /showing the layout of UST system is complete and accurate . <br /> UST Service Technician Signature <br /> e <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not applicable <br />