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UNDERGROUND STORAGE TANK <br />CERS = California Environmental Reporting System, ID =Identification, ICC = International Code Council, <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 />I. FACILITY INFORMATION <br />CERS ID <br />Date of Monitoring System Certification <br />10181293 <br />12/21/18 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Building # <br />GRUPE COMERCIAL <br />Business Site Address City <br />ZIP Code <br />5000 S LINDBERGH ST STOCKTON <br />95206 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />Phone # <br />Afforda Test <br />(209) 744-0112 <br />Mailing Address <br />416 2nd Street Galt CA 95632 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />Edward Stearns <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />14-1760 Ex. 9/30/20 <br />888308MT <br />11/9/2020 <br />Monitoring System Training and Certifications List all applicable certifications. <br />Expiration <br />Date <br />Veeder Root A31048 <br />6/3/2020 <br />Incon 1009893708 <br />11/30/2020 <br />III. RESULTS OF TESTING I SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />Y <br />N <br />NA <br />QX Monitoring System Set-up [X Alarm History Report <br />Was any monitoring equipment replaced? <br />El <br />M <br />El <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 />El <br />(If "Yes, " describe what was found in section IV below) <br />Is all monitoring equipment operational per manufacturer's specifications? <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 />JAN 14 20'" <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 showing the layout of UST system is complete and accurate. <br />UST Service Technician Signature <br />/� <br />ii Ir7`l <br />Y = Yes, N = No, NA =Not Applicable <br />