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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 of this form <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br /> USTs within 30 days of the date of the monitoring system certification . <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181913 02/ 12/2019 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> Shell <br /> Business Site Address City ZIP Code <br /> 16500 S . Harlan Road Lathrop , CA 95330 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> ECO- CHEK Compliance , Inc . ( 888) 500 - 2435 Ext , 2 <br /> Mailing Address <br /> P . O . 1394 , Lafayette , CA 94549 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br /> Nik Zagorov <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 958763 5264361 05/08/2019 <br /> Monitoring System Training and Certifications List all applicable certifications.) Expiration Date <br /> Veeder Root Level 4 # A32784 12/06/2020 <br /> Vaporless LDT- 890 # 1794 02/27/2020 <br /> S Bravo #SWAT 04/06/2019 <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 /> ® Monitoring System Set-up ® Alarm History Report <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 /> Was damage, debris , or liquid found inside any secondary containment systems? <br /> (If "Yes, " describe what was found in section IV below.) El 0 El <br /> Is all monitoring equipment operational per manufacturer's specifications? <br /> (If "No. " describe why in section IV below.) 0 El El <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 CONDUCTING THIS TESTING <br /> 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 /> C7 r ©✓ <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = Intemational Code Council, Y = Yes, N = No, NA = Not applicable <br />