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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 monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10184563 6/21/19 <br /> Business Name(Same as Fac/W Name or DBA-Doing Business As) Building <br /> Chevron 7T <br /> Business Site Address City ZIP Code <br /> 3400 N.MacArthur Tracy 95376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Service Station Systems 4089712445 <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 /> Steve Parmenter <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8818846-UT 2/24/2021 <br /> Monitoring System Trainino and Certifications Lrst all i—pplicable certifications. Expiration Date <br /> VMI-2379 3/28/2021 <br /> WR-A28780 4/4/2021 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports If the monitoring equipment is capable of generating either. Y N NA <br /> 0 Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced? <br /> (If"Yes,"identify the speck devices replaced and list the manufacturerand model for all replacement parts in section IV below.) <br /> El 9 El <br /> Was damage,debris,or liquid found inside any secondary containment systems? <br /> (if"Yes,"describe what was found In section lV below.) 11 91 El <br /> Is all monitoring equipment operational per manufacturer's specifications? Ga ❑ <br /> (lf"No,"describe why in section IV below.) _ <br /> IV. COMMENTS <br /> If dire cfed to use this section,describe how and when the issues were or will be corrected. <br /> RECEIVE <br /> !-Lb 0 5 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 sitelap n showing the lal out of UST system is complete and accurate. <br /> UST Service Technician Signature �Q <br /> CERS=Cal'domia Environmental Reporting System,ID=Identification,ICC=International Code Council,Y=Yes,N=No,NA=Not Applicable <br />