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UNDERGROUND STORAGE TANK <br />CERS = California Environmental Reporting System, ID =Identification, ICC = International Code Council, <br />MONITORING SYSTEM CERTIFICATION FORM (Pagel of 6) <br />�j <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 <br />10181363 1 <br />Date of Monitoring System Certification <br />11/27/18 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Building # <br />CHARTER WAY SHELL <br />Business Site Address City <br />620 CHARTER WAY STOCKTON, CA <br />ZIP Code <br />95206 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />Phone # <br />AFFORDA TEST <br />(209) 744-0112 <br />Mailing Address <br />416 2ND ST. GALT, CA 95632 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />FELIX RAMIREZ <br />Contractor / Tank Tester License # <br /># <br />ICC Certification Expiration Date <br />08-1740 Ex.3/31 /20 <br />T1C`CCertification <br />8883072 -UT <br />11 /22/2018 <br />Monitorin System Training and Certifications List all applicable certifications. <br />Ex iration Date <br />Veeder Root B34976 <br />7/7/2020 <br />ICC 5273934 <br />11/17/2020 <br />VMI 2517 <br />11/06/18 <br />CONTRACTOR 341375 <br />III. RESULTS OF TESTING / SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />❑x Monitoring System Set-up ❑X Alarm History Report <br />y <br />N <br />NA <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 />0 <br />❑ <br />X <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />El <br />D <br />X❑ <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. <br />oxF' <br />JINN q� 2019 <br />NY <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 <br />Y = Yes, N = No, NA = Not Applicable <br />