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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel 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 IDof Monitoring System Certification <br /> Date <br /> 10181239 7712/ 14/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> A&A GAS <br /> Business Site Address City ZIP Code <br /> 16 E HARDING WAY STOCKTON , CA 95203 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> AFFORDA TEST (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 /> EDWARD STEARNS <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14 - 1760 Ex . 9/30/20 8883080- UT 11 /9/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A31048 6/3/2020 <br /> Incon 1009893708 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, y N NA <br /> [X Monitoring System Set-up QX Alarm History Report <br /> Was any monitoring equipment replaced ? El F 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? E X❑ 11 <br /> (If "Yes, " describe what was found in section IV below) <br /> Is all monitoring equipment operational per manufacturer's specifications? El ED <br /> (If 'No, " describe why in section IV below.) <br /> IV. COMMENTS <br /> j If directed to use this section, describe how and when the issues were or will be corrected. <br /> Iti <br /> Ir1 � <br /> � E <br /> i <br /> E <br /> PF <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 Signature1 117 <br /> r <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = Intemational Code Council, Y = Yes, N = No, NA = Not Applicable <br /> j <br /> i <br />