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UNDERGROUND STORAGE TANK <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, <br />MONITORING SYSIli TEM CERTIFICATION FORM (Page 1 of s) <br />ION <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 <br />Date of Monitoring System Certification <br />101810611 <br />1 11/9/2018 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />Building # <br />Lodi Memorial Hospital <br />I N/A <br />Business Site Address <br />City <br />ZIP Code <br />975 S. Fairmont Ave <br />JlLodl 195240 <br />II. UNDERGROUND STORAGE TANK SERVICE <br />TECHNICIAN INFORMATION' <br />Name of Company Performing the Certification <br />Phone # <br />Elite IV Contractors <br />(209) 461-6337 <br />Mailing Address <br />2535 Wigwam Dr Stockton, CA 95205 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />Christopher Adams <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />1001331 HAZ -j <br />8230218 <br />4/17/2020 <br />Monitoring System Training and Certifications List all applicable certifications. <br />Expiration Date <br />Veeder-Root TLS 643531 <br />9/27/2019 <br />III. RESULTS OF TESTING [SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />❑ Monitoring System Set-up ❑ Alarm History Report <br />Y <br />N <br />NA <br />Was any monitoring equipment replaced? <br />❑ <br />❑ <br />Q <br />(if "Yes, "identify the specific devices replaced and list the manufacturer and model for all replacement parts In section WWI <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />❑ <br />❑ <br />x❑ <br />(if "Yes,"describe what was found in section IV below.) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />❑ <br />(If "No,"describe why In section IV below.) <br />1V. COMMENTS <br />If directed to use this section, describe how and when the Issues were or will be corrected. <br />Return to complete Monitor Certification originally done on 10/16/18 by Aforda-Test <br />Meet Inspector on site for end of the line communication testing only <br />Y' x <br />if <br />NOV <br />ENVIRIONMEENL AL HEALT <br />r)iF,FIA T �Ai .iP <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 layout of UST system is complete and accurate. <br />US We fto SignAure <br />Y = Yes, N = No, NA = Not Applicable <br />