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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 /> agency 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 /> 10181231 12/12/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building <br /> Speedway 4945 <br /> Business Site Address City ZIP Code <br /> 401 W.Kettlemen Ln. Lodi 95240 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Service Station Systems,Inc. (408)971-2445 <br /> Mailing Address <br /> 680 Quinn Ave.,San Jose 95112 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> Randy Wilkerson <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8822029 12/16/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root TLS 3XX A32404 3/17/2021 <br /> Vaporless Manufacturing Inc#2273/4576 12/12/2021 <br /> Red Jacket#A32404 3/18/2021 <br /> FE PETRO#1001093708 12/12/2021 <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 /> Z Monitoring System Set-up W1 Alarm History Report <br /> Was any monitoring equipment replaced? <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? <br /> (If'Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? <br /> (if"No,"describe why in section iV below.) WI 1:1 El <br /> IV. COMMENTS <br /> if directed to use this section,describe how and when the issues were or will be corrected. <br /> rh-% E'f*N <br /> Replaced 91 MLLD-Retested&Passed. A r <br /> F EB 2 4 2020 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <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 verity that this information and the site plan showing the layout of UST system is complete and accurate. <br /> UST Service Technician Signature - <br /> CERS=California Environmental Reporting System,ID=ktenlilication,ICC=International Code Cound,Y=Yes,N=No,NA=Not Applicable <br />