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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 /> Is FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10165777 10/7/2019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) Building # <br /> 7- ELEVEN 14113 , MKT 2368 <br /> Business Site Address City : Zip : <br /> 3040 BENJAMIN HOLT DR @ GRIGSBY STOCKTON 95219 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> TANKNOLOGY INC . (800) 800-4633 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 /> Clint Fuhrman <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 9160945 5/2/2021 <br /> Monitoring System Training and Certifications (List all applicable certifications . ) Expiration Date <br /> Tanknology Certification Level III ATG Operability Training Certification Exam 96735 02/04/2022 <br /> ICC CA UST Service Technician 9160945 05/02/2021 <br /> Veeder Root ATG Technician C26533 04/25/2021 <br /> Ill . RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA ' <br /> W Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced ? 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 <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 /> i <br /> Complete monitor cert performed in work order 2342147 ... Only tested communication for vph in dispensers for product lines . <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 <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 /> CERS=California Environmental Reporting System , ID=Identification, UST=Underground storage tank, ICC=International Code Council <br /> i <br />