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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 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 /> 10-19-18 <br /> Business Name(Same as Facility Name or DBA—Doing Business As.) Building# <br /> FED EX <br /> Business Site Address City ZIP Code <br /> 5655 HOOD WAY TRACY CA. <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> FRANZEN-HILL (559) 688 - 2977 Ext. <br /> Mailing Address <br /> 1100 N. J STREET TULARE CA. <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification.) <br /> MARK WILLIAMS <br /> ContractorfTank Tester License# ICC Certification# ICC Certification Expiration Date <br /> A304137 8198890 5-1-20 <br /> Monitoring System Training and Certifications(List all applicable certifications.) CL, .;�, x il"etio Date <br /> VEEDER ROOT 843562 Wirt <br /> III. RESULTS OF TESTING/SERVICING q� <br /> Indicate and attach the following reports if the monitoring equipment is capable ofgen �l iV"MEN Y N NA <br /> El Monitoring System Set-up ❑-Aarm is T IT <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 W below.) <br /> Was damage,debris,or liquid found inside any secondary containment systems? ❑ ® ❑ <br /> (If"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ® ❑ 0 <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. <br /> THIS TEST IS DUE TO NOV FOR NOT BEING ABLE TO SHOW COMMUNICATION OF PIPING SECONDARY <br /> HOOKED TO A CONTINUOUSLY MONITORED VR SEECONDARY CONTAINMENT VACUUM SENSOR <br /> DURING AANNUAL MONITORING CERTIFICATION PERFORMED BY ANOTHER CONTRACTOR. <br /> REPLACED S1 VAC SENSOR WITH IDENTICAL SPARE VAC SENSOR THAT WAS LOCATED IN SUMP <br /> THAT WAS NOT BEING USED DUE TO DEFECTIVE SENSOR. <br /> CLEARED GLUE FROM SECONDARY PORT IN UDC #5 <br /> INSTALLED BALL VALVE IN VENT TRANSITION SUMP ON VENT LINE SECONDARIES FOR PROVING <br /> COMMUNICATION OF PIPING DURING TESTING. <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 /> US e Technician n ture � <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=International Code Council,Y=Yes,N=No,NA=Not applicable <br />