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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM <br /> This form must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy of this form <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br /> 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 /> 10184311 3 - 12 -2020 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> United Pacific #5449 <br /> Business Site Address City ZIP Code <br /> 322 South Center Street Stockton 95203 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> CGRS ( 916 ) 991 - 1100 <br /> SOLUTIONS DELIVERED <br /> Mailing Address <br /> 5444 Dry Creek Road ; Sacramento , Ca . 95838 <br /> Name of UST Service Technician Performing the Certification (Printas shown on the ICC Certification.) <br /> Garrett Warren <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB# 803616 8185019 9-20 -2021 <br /> Monitoring System Training and Certifications (List all applicable certifications.) Expiration Date <br /> B42126 Veeder- root 1 -21 -21 <br /> VMI LDT- 890 Tester/ #3822 4 -30-20 <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 El Alarm History 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 IV ❑ I] ❑ <br /> below. <br /> Was damage, debris, or liquid found inside any secondary containment systems? ❑ 0 ❑ <br /> (If "Yes, " describe what was found in section IV below.) <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. 1� <br /> a <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 1 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 Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not applicable <br />