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RECEIVED <br /> 20202418 . 1 Ajj , - r <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel of s <br /> This form must be used to document testing and servicing of underground storage tank (UST) o rti� c I <br /> of this form must be provided to the UST owner or operator. The owner or operator must submit a copy 4 is/"" �@illocal <br /> agency regulating the 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 /> 8/6/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> FedEx Freight Stockton <br /> Business Site Address City ZIP Code <br /> 4520 S . Hwy 99 Stockton 195215 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification TPhone # <br /> Gettler- Ryan Inc , (925 ) 5514555 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G , Dublin , CA 94568 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Alexander Tate <br /> Contractor 1 Tank Tester License # IGC Certification # ICC Certification Expiration Date <br /> 220793 88839104T 3 /412021 <br /> Monitoring System Training and Certifications list all applicable ceritificatforisj Expiration Date <br /> Veeder Root TLS3XXX Tech Cert # 1342662 1 /3 /2021 <br /> VMI Line Leak # 3634 11 /6/2021 <br /> VMI LDT- 890 Leak Detector Tester #3635 11 /6/2021 <br /> III . RESULTS OF TESTING t 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 x Alarm History Report <br /> Was any monitoring equipment replaced ? ❑ a ❑ <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? ❑ ❑X ❑ <br /> (if "Yes, " describe what was found in section IV below ) <br /> Is all monitoring equipment operational per manufacturer's specifications? El(It 'No, " describe why in section IV below) <br /> N El 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 /> I 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 skowing the layout of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS = California Envhxyriental Reporting System, ID Identification, ICC = iniemalional Code Council. Y = Yes, N = No, NA = Not Applicable <br />