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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 <br /> local agency regulating the USTs within 30 days of the date of the monitoring system certification . <br /> I . FACILITYINFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10165815 9/23/2020 <br /> Business Name (Same as Facility Name or DBA- Doing Business As .) Building # <br /> 7-ELEVEN #17334 MKT 2368 (N-747) <br /> Business Site Address City : Zip : <br /> 4501 N . PERSHING AVE . @ ROSEMARIE LN . STOCKTON 95207 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> TANKNOLOGY INC . (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 # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/13/2021 <br /> Monitoring System Training and Certifications List all applicable certifications . Expiration Date <br /> Tanknology Certification Level III ATG Operability Training Certification Exam 115235 12/31 /2022 <br /> ICC CA UST Service Technician 8361393 06/13/2021 <br /> Tanknology Certification Level III LDT-5000 FTA Certification Exam 115237 01 /27/2022 <br /> Veeder Root API - POST B45334 02/14/2021 <br /> Ill . RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NAI <br /> Iw Monitoring System Set-up W Alarm History Report <br /> Was any monitoring equipment replaced? <br /> r r 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 ? r r r— <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? F- <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 - ) N <br /> Replaced LD on 87 reg . stp sump . Due to a bad leak detector. . . <br /> f �� iP 9`? _384 I `e.A i'� �` f� i� t it <br /> NUi ' fa I I tit P � ai <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 <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 /> /r�ow � <br /> CERS=California Environmental Reporting System , ID=Identification , UST=Underground storage tank, ICC=International Code Council <br />