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01 <br />I <br />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 />11/08/2018 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />Unified Grocers, Inc. <br />Building # <br />Business Site Address <br />1990 Piccoli Rd. <br />City <br />Stockton <br />ZIP Code <br />95215 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />TAIT Environmental Services, Inc. <br />Phone # <br />(714) 560-8222 <br />Mailing Address <br />11280 Trade Center Dr., Rancho Cordova, CA 95742 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />Jarrett Flewellyn <br />Contractor / Tank Tester License # <br />588098 <br />ICC Certification # <br />8028164 <br />ICC Certification Expiration Date <br />03-29-2019 <br />Monitoring System Training and Certifications (List all applicable cedificalions.) Expiration Date <br />Gilbarco Veeder Root - B36959 07-04-2019 <br />III. RESULTS OF TESTING / SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />Alarm History Report NA X Monitoring System Set-up X <br />Was any monitoring equipment replaced? <br />(If "Yes," identify the specific devices replaced and list the manufacturer and model for all replacement pads in section IV below.) X <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />(If "Yes," describe what was found In section IV below.) X <br />Is all monitoring equipment operational per manufacturer's specifications? <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 />The Power indicator light and Warning indicator light was replaced the monitoring panel. <br />Removed approximately .25 gallons from the Hi Flow piping sump. <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 />paw& 76..44, <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y= Yes, N = No, NA = Not Applicable