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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Pagel of 6) This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy 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 agency regulating the USTs within 30 days of the date of the monitoring system certification . I . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10456027 5/22/ 19 Business Name (Same as Facility Name or DBA-Doing Business As) Building # TRACY 76 Business Site Address City F ZIP Code 2420 W. GRANTLINE RD TRACY , CA 195376 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # AFFORDA TEST (209 ) 744- 0112 Mailing Address 416 2ND ST GALT , CA 95632 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) EDWARD STEARNS Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 14 - 1760 Ex . 9/30/20 8883080 - UT 11 /9/2020 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder Root A31048 6/3/2020 Incon 1009893708 11 /30/2020 III . RESULTS OF TESTING I SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA ❑X Monitoring System Set-up ❑X Alarm History Report Was any monitoring equipment replaced ? F] R R (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) Was damage , debris , or liquid found inside any secondary containment systems? (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? (If "No, " describe why in section IV below.) N El El IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. DIESEL FLOAT IN DISPENSER 7/8 CRACKED WILL NEED TO REPLACE - REpairs and retest by Elite IV RECE � i I' ( ( i, l :j ENVIRONMENTAL I I I DEPAP T 14FNP. , V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations , Title 23 , Division 3, Chapter 16 , Section 2638 and all information contained herein is true and accurate. Attached to this certification is information (e .g . , manufacturers ' checklists , monitoring system set-up, alarm history report, etc .) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature CERS = California Environmental Reporting System, ID = Identification, ICC = Intemational Code Council, Y = Yes, N = No, NA = Not Applicable