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UNDERGROUND STORAGE TANK <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 /> L FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181511 7/29/ 19 <br /> Business Name (Same as Facility Name or DSA-Doing Business As) Build ng # <br /> KwikSery #98 <br /> -� Cit =95320 <br /> de <br /> Business Site Address y <br /> 2501 Jackson Ave . Escalon <br /> Ii . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems (408) 971 -2445 <br /> Mailing Address <br /> 680 Quinn ave San Jose Ca, 95112 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the iCC Certification) <br /> Brian McPheely <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> j 485184 8822062 11 /9/2019 <br /> Monitorin stem Training and Certifications List all applicable certifications.) Expiration Date <br /> VR B36745 2/27/2020 <br /> VMI 11 /29/2019 <br /> R <br /> — —LL 11 /14/2019 <br /> Red Jacket <br /> 111 . RESULTS OF TESTING I SERVICING _ <br /> Indicate and attach the following reports if the monitoring equipment Is capable of generating either. Y N NA <br /> Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced? El 0 <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section ! V below.) <br /> Was damage , debris, or liquid found inside any secondary containment systems? 1 <br /> (if "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? 0 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 /> Ft E Cv <br /> L HEAL <br /> rE NV IRON NA EN P\ <br /> Ne <br /> OR <br /> � i <br /> s , <br /> j <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 1 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 showin the la out of USTs stem is corn tete and accurate. <br /> UST Service Technician Signature <br /> CERS = California Environmental Reporting System, ID = identification, ICC = international Code Council, Y = Yes, N = No, NA = Not Applicable <br />