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UNDERGROUND STORAGE TANK <br />CERS = California Environmental Reporting System, ID= Identification, ICC = International CodeCouncil, Y = Yes, N= No, NA= NotApplicable <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 />10181013 <br />Date of Monitoring System Certification <br />5/2/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Building # <br />Quick Stop Market #120 <br />Business Site Address City <br />9321 Thornton Road Stockton <br />ZIP Code <br />195209 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />one # <br />Walton Engineering, Inc. <br />(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 / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />617238 <br />8167865 <br />5/13/2020 <br />Monitoring System Training and Certifications List all applicable certifications. <br />Expiration Date <br />Veeder-Root <br />12/4/2020 <br />Va orless - VMI <br />2/4/2021 <br />III. RESULTS OF TESTING / SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />Q Monitoring System Set-up QX Alarm Histoa 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 />F1 <br />[9 <br />El <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? <br />❑ <br />El <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 />Removed a small amount of water from the 87 fill sump. Removed 13.5 gallons of water from the 91 fill sump <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 />