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UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (pagei 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 <br />Date of Monitoring System Certification <br />10181579 <br />1/24/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />I Building # <br />BAGLEY -TRACY UNIFIED SCHOOL <br />11 <br />Business Site Address <br />Ciry <br />ZIP Cade <br />1970 W LOWELL <br />I TRACY, CA <br />195376 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification Phone # <br />AFFORDA TEST (209) 744-0112 <br />_ <br />Mailing Address <br />416 2ND STREET GALT, CA 95632 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />FELIX RAMIREZ <br />Contractor / Tank Tester License # <br />ICC Certification # ICC Certification Expiration Date <br />08-1740 Ex.3/31/20 <br />I 8883072 -UT 11/9/2020 <br />Monitoring Svstem Training and Certifications (List all anolicab)e certifications.) Expiration Date <br />Veeder Root B34976 7/7/2020 <br />Incon 1009883708 11/30/2020 <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 />X Monitoring System Set-up x❑ Alarm Historlt 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 lV below.) <br />El <br />ME <br />El <br />Was damage, debris, or liquid found inside any seoondary containment systems? <br />(ff 'Yes,"describe what was found in section IV below.) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />© <br />❑ <br />0 <br />(if "No,"describe why in section 1V below.) <br />IV. COMMENTS <br />1f directed to use this section, describe how and when the issues were or will be corrected. <br />I TOUCH Certification completed by Bagley Enter. on site same day/time. <br />Tech: Eric Molgaard <br />Cert: 902443 <br />H�ALT11 <br />ER���RpNti9cNT/�� <br />DF -. <br />V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />I hereby certify that the equipment identified In this document was inspectediserviced 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 systarfs complete and accurate. <br />UST Service Technician Signature/ <br />CERS = C trija &m mrerRal Reportig System, ID = IdrnftAm, M = final Code Council, Y = Yes, N = No, NA = Not AppiG4* <br />