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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 /> L FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10184365 12/12/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Gas 4 Less <br /> Business Site Address City ZIP Code <br /> 3408 Manthey Rd . Stockton 95206 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems , Inc. (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 /> Kristopher S Bell <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8833000 7/22/2020 <br /> Monitoring System Training and Certifications List all a licable certifications. Expiration Date <br /> Veeder Root 3/25/2021 <br /> V. M . I 10/31 /2020 <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 /> © <br /> Monitoring System Set-up 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 below.) <br /> Was damage, debris, or liquid found inside any secondary containment systems? El W1 R <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 /> 1V. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> 3 f <br /> JAN 0 2020 <br /> I <br /> i <br /> Ir Ti L <br /> i <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 t � <br /> Not Applicable <br /> CERS = Califomia Environmental Reporting System, ID = Identrf'ication, ICC = International Code Council, Y = Yes, N = No, NA = <br />