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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 monitorin_q system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181411 11/2/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building <br /> Tracy Blvd Shell&Mini Mart <br /> Business Site Address City ZIP Code <br /> 3725 N Tracy Blvd. Tracy 95376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Service Station Systems (408)971-2445 <br /> Mailing Address <br /> 680 Quinn ave San Jose Ca,95112 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> Brian McPheely <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8822062 11!1/2021 <br /> Monitorino Svstem Traininq and Certifications List all applicable certifications.) Expiration Date <br /> Veeder Root TLS 3XX B36745 11121/2021 <br /> Vaporless Manufacturing Inc#3803 10129/2021 <br /> Red Jacket#636745 10/29/2021 <br /> FE PETRO#1014303708 11/21/2021 <br /> III. RESULTS OF TESTING 1 SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> W1 Monitoring S stem Set-up Alarm History Report <br /> Was any monitoring equipment replaced? El m El <br /> (If"Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section lV below.) <br /> Was damage,debris,or liquid found inside any secondary containment systems? Z El El <br /> (If"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? m El ❑ <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 /> Removed Liquid from 91 Fill Sump. ) r• 77 <br /> `i9g <br /> rYi� ' r ave Wv J <br /> i JAN 3 0 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 verify 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 Ernrironmental Reporting System,ID=Identification,ICC=International Code Courict,Y=Yes,N=No,NA=NotApplicable <br />