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RECEIVED <br /> J 1 13 2020 <br /> v 1�ENTAL lAiE \ LTH <br /> UNDERGROUND STORAGE TANK [) PPAPl 107Ni , <br /> MONITORING SYSTEM CERTIFICATION FORM (Pam i of s <br /> This form must be used to document tasting 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 ar operator must submit a copy of this form to the local <br /> agengy regulatingthe USTs within 30 days of the date of the monitoring stem certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date or Monitabg System Cedlniatton <br /> 10180733 1 6/18/2020 <br /> Business Name (Same as F=Wy Nems brDBA-D ft Business As) 06141590 <br /> Arco 7147 <br /> Bushass SU Addross CRY ZIP Code <br /> 1206 E March Lane I Stockton 95210 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Petiaming the CeAlRcaft Phone p <br /> Gelder-Ryan Inc. (925) 5514555 <br /> Maling Addrm <br /> 6805 Sierra Court, Suite G , Dublin , CA 94568 <br /> Name of UST Service Technician Perforaft the CenlHcallm (Pft asshaman WICC Ce A31ron) <br /> Damell Smith <br /> Contrador f Tank Tester license * ICC CerARcation # ICC Cadlttcs0on ExpWon Date <br /> 220793 8709494 11 /23/2021 <br /> MoN TrAft and Certtk9ans alst at! Egleft ceHt wWons Ex kaUon Date <br /> Veeder Root TLS3XXX Tech Cert 848857 3/23/2022 <br /> VMI Line Leak # 4070 6/1212021 <br /> i <br /> VMI LDT•890 Leak Detector Tester # 4071 6/27/2021 <br /> Ill. RESULTS OF TESTING / SERVICING <br /> Indicate and attach the folioWng reports If the monitoring equipment Is capable of generating either. Y N NA <br /> Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced? u ® 0 <br /> (if "Yee,'fdw* the specNfc devices replaced and list Mee marwractta wand modallbragroplecement parts to sadbn Wbobw.) <br /> Was damage, debris, or 8quld found Inside any secondary containment systems? <br /> (N "Yes valasofbs what was foundin section MOW.) <br /> Is ak monitoring equipmant operational per manufadurePs speciffeefions? <br /> (1(*No, "desalbe whyb aecUon N bebw.) <br /> N. COMMENTS <br /> Ndkedod to use Mds sadkim desolbe how and when the issues were or wg be cmroded. <br /> Cleaned out water inside of dispensers 718 and 9110 <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified In this document was inspectadlservlced In accordance with California Code of <br /> Regulations, Title 23, Division 3, Chapter 16t Section 2638 and all Information contained herein Is true and accurate. Attached in <br /> this certification is Information tam" manufacturors' checklists, monitoring system setup, alarm history report, e(c.) necessary <br /> to verily that this Information and the alto-aWm4howlanihs bWgg of UST system Is complete and accurate. <br /> UST Service Techmmn Signa urs 2 <br /> pow <br /> r <br /> C�iSIICadon�telm+torrshdtd Syctaln iDpklen, iCC � tderr�lor►alCodeCou�d, Y= Yes,NRNo, NA= NdAppkshte <br />