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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 s stem certification, <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10785304 3/3/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> AGS DBA Chevron <br /> Business Site Address City ZIP Code <br /> 1490 South Main Street I Manteca 195337 <br /> lie UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Walton Engineering , Inc . (916) 372= 1888 <br /> Mailing Address <br /> P . O. Box 1025 , West Sacramento, CA 95691 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Curtis Carpenter <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8167865 5/13/2020 <br /> Monitoring System Training and Certifications List all iFpflcable certfikations. Expiration Date <br /> Veeder-Root 12/4/2020 <br /> Va orless - VMI 2/4/2021 <br /> lif. RESULTS OF TESTING / SERVICING <br /> indicate and attach the following reports N the monitoring equipment Is capable of generating either. y N INA <br /> N Monitoring System Set-up X Alarm History Report <br /> Was any monitoring equipment replaced? N(If *Yes, " identify the specUic devices replaced and list the manufacturer and model for all replacement parts In section IV below.) El <br /> Was damage, debris, or liquid found inside any secondary containment systems? 0 <br /> (ff "Yes, " describe what was found in section 1V below.) El 1:1 <br /> is all monitoring equipment operational per manufacturer's specifications? a <br /> (If No, " describe why In section iV below.) <br /> IV. COMMENTS <br /> ffdirected to use this section, describe how and when the issues were or will be corrected. <br /> Removed a small amount of liquid from all three Fill sumps. <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 verify that this information and the site plan showing the layout of UST system is complete and accurate. <br /> UST Service Technician Signature�� <br /> r <br /> CERS = Cafifania Environmental Reporting System, ID = Identification, ICC = In1wrrational Code Counal, Y = Yes, N = No, NA= Not Applicable <br /> I <br />