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UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (Pagel 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 monitorina s stem certification. <br />I. FACILITY INFORMATION <br />CERS ID I Date of Monitoring System Certification <br />10181487 15/21/20 <br />Business Name (Same as Facility Name or DBA -Doing Business As) Building # <br />Speedway 4612 <br />Business Site Address <br />City <br />ZIP Code <br />2448 W Kettleman Ln. <br />I Lodi <br />95242 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />Phone # <br />Service Station Systems, Inc. <br />(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 />Brian McPheely <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />485184 <br />8822062 <br />11/1/2021 <br />Monitoring System Training and Certifications(List all applicable certifications. Expiration Date <br />Veeder Root TLS 3XX B36745 11/21/2021 <br />Vaporless Manufacturing Inc #3803 10/29/2021 <br />Red Jacket #1336745 10/29/2021 <br />FE PETRO #1014303708 11/21/2021 <br />III. RESULTS OF TESTING i SERVICING <br />Indicate and attach the following reports if the monitoring equipment Is capable of generating either. <br />Y <br />N <br />NA <br />Monitoring System Set-up Alarm History Report <br />Was any monitoring equipment replaced? <br />" <br />El <br />m <br />El <br />(if 'Yes, identify the specific devices replaced and list the manufacturer and model for all replacement parts in section 1V below.) <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />E] <br />m <br />❑ <br />(11"Yes,"describe what was found in section 1V below) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />"No," <br />m <br />(if 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 />R <br />�T ACTH <br />NVIR�NM�'.IT�� <br />E �n�IEN <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 />~rZ� <br />CERS = Caldomia Environmental Reporting System, ID = Identification, ICC = International Code Counal, Y= Yes, N = No, NA = Not Applicable <br />