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UNDERGROUND STORAGE TANK <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, <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 />I. FACILITY INFORMATION <br />CERS ID <br />Date of Monitoring System Certification <br />10180913 <br />1/15/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Building # <br />ERNIES GENERAL STORE <br />Business Site Address City <br />ZIP Code <br />4407 E WATERLOO RD STOCKTON, CA <br />95215 <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 />ICC Certification # <br />ICC Certification Expiration Date <br />08-1740 Ex.3/31 /20 <br />8883072 -UT <br />11/9/2020 <br />Monitordinq System Training and Certifications List all applicable certifications. <br />Expiration Date <br />Veeder Root B34976 <br />7/7/2020 <br />Incon 1009883708 <br />11/30/2020 <br />III. RESULTS OF TESTING / SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />Y <br />N <br />NA <br />OX Monitoring System Set-up Alarm History Report <br />Was any monitoring equipment replaced? <br />El <br />M <br />El <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? <br />❑ <br />X❑ <br />El <br />(If "Yes, " describe what was found in section IV below.) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />X <br />❑ <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 />�ixrz�j <br />did - <br />JAN 2 9 2019 <br />EivitIHvI'A1M1LNTAL <br />H7.-.Anv=PaPTPENT <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 />