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<br /> HThis 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 fort to the local
<br /> agency regulating the USTs within 30 days of the date of the monitoringgs, stem% certification. u,..,. .,� , . . r.•
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<br /> CERS ID Date of Monitoring System Certification
<br /> 10180603 2/22/19
<br /> Business Name (Same as Facility Name or DSA-Doing Business As) Building #
<br /> RUPI — BILL'S 76
<br /> Business Site Address City ZIP Code
<br /> 633 VICTOR RD LODI , CA 95240
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<br /> Name of Company Performing the Certification Phone #
<br /> AFFORDA TEST (209) 744-0112
<br /> Mailing Address
<br /> 416 2ND ST. GALT, CA 95632
<br /> Name of UST Service Technician Performing the Certification (Print es shown on the iCC Certification)
<br /> EDWARD STEARNS
<br /> Contractor / Tank Tester License # ICC Certification # ]CC Certification 5xpiration Date
<br /> 14- 1760 Ex. 9/30/20 8883080-UT 11 /9/2020
<br /> Monitoring System TrainlDg and Certifications List a// applicable certification&j Expiration Date
<br /> Veeder Root A31048 6/312020111111111111111111,
<br /> ( noon 1009893708 11 /30/2020
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<br /> Indicate and attach the following reports K the monitoring equipment is capable of generating either. ' = °` :ppI.`" ''
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<br /> Monitoring System Set-up Alarm History Report
<br /> Was any monitoring equipment replaced?
<br /> (If 'Yes� " identify the speciro devices replaced and list the manufacturer and model forall 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 /V below.)
<br /> is all monitoring equipment operational per manufacturer's specifications?
<br /> (if No, " dasedba why in section IV below.) R El El
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<br /> If directed to use this section, describe how and when the issues were or will b® corrected.
<br /> FOUND 91 FILTER LEAKING IN DiSPENCER 1 -2 TIGHTENED FILTER LEAK STOPPED.
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<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' checkllsts, monitoring system setup, alarm history report, etc.) necessary
<br /> to verify that this information and the site plan showin the la out of UST stem is complete and accurate.
<br /> UST Service Technician Signature
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<br /> CERS = Caifw iaa EnAmili r>erdci Repo” System, Ib = ldentilicalion, ICC = hitma6anal Code Council, Y = Yes, N = Pio. NA " Not Appy
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