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UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATIONFORM (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 <br />local agency regulating the USTs within 30 days of the date of the monitoring system certification. <br />Is FACILITY' INFORMATION <br />CERS ID <br />Date of Monitoring System Certification <br />1 <br />10770799 <br />4/19/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As.) <br />Building # <br />7 -Eleven 38153 <br />Business Site Address <br />City: <br />Zip: <br />121 S. Center Street <br />Stockton <br />95202 <br />11. UNDERGROUND STORAGE <br />TANK <br />SERVICE TECHNICIAN <br />INFORMATION <br />Name of Company Performing the Certification <br />Phone # <br />TANKNOLOGY INC. <br />(800) 8004633 Ext. <br />Mailing Address <br />11000 N. Mopac Expressway #500, Austin, TX 78759 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br />Jesus Saldivar <br />Contractor/Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />Class A General Engineering 743160 <br />8361393 <br />6/16/2019 <br />Monitoring System Training and Certifications List all applicable certifications.) <br />Expiration Date <br />Tanknology Certification Level III ATG Operability Training Certification Exam 115235 <br />07/19/2019 <br />ICC CA UST Service Technician 8361393 <br />06/16/2019 <br />Veeder Root VR Level 4 845334 <br />05/01/2019 <br />VMI TLDT-5000 Tester 3802 <br />11/20/2019 <br />III. RESULTS OF TESTING/SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />N <br />NA <br />W Monitoring System Set-up � Alarm History Report <br />Was any monitoring equipment replaced? <br />Fr� <br />r <br />r <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 />W0 <br />r <br />(I"Yes, " describe what was found in section IV below.) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />r <br />r <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 />V. CERTIFICATION BY UST SERVICE TECHNICIAN <br />CONDUCTING <br />THIS TESTING <br />1 hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code <br />of <br />Regulations, title 23, division 3, chapter 16, section 2638 and all information contained herein is true and accurate. Attached <br />to this certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) <br />necessary 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 />CERS=California Environmental Reporting System, ID=Identification, UST=Underground storage tank, ICC=International Code Council <br />