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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 local <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 /> 10156819 6/18/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Safeway 1 <br /> Business Site Address City ZIP Code <br /> 1987 W . 11th St. Tracy 95376 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems (408) 971 -2445 <br /> Mailing Address <br /> 680 Quinn Ave , San Jose Ca, 95112 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Steven Parmenter <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 465184 8818846 2/24/2021 <br /> Monitoring System Training and Certifications (List all applicable certifications.) Expiration Date <br /> Veeder Root-A28780 4/4/2021 <br /> VMI -2259 3/28/2021 <br /> FE-PETRO- 1002603708 8/9/2020 <br /> III . RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y FW NA <br /> Monitoring System Set-up Z Alarm History Report <br /> Was any monitoring equipment replaced? <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) El Z El <br /> Was damage , debris , or liquid found inside any secondary containment systems ? F1 0 E <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 lV below.) z El <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> R Ez� <br /> / 0 <br /> `NVIROWi` <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 /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br />