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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 -I 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 />10180899 <br />1 2/12/19 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Building # <br />WILSON WAY CHEVRON <br />Business Site Address City <br />ZIP Code <br />437 N WILSON WAY STOCKTON, CA <br />95205 <br />ll. 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 ST. 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 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 />X Monitoring System Set-up ❑X Alarm Histwy Report <br />Was any monitoring equipment replaced? <br />F] <br />N <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 />0 <br />X <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. <br />a <br />� t <br />AU <br />WAffi €�"'ri m,�l 6 E <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 />Y = Yes, N = No, NA Not Applicable <br />= <br />