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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page f 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 /> 10184365 112/10/ 18 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Gas 4 Less <br /> Business Site Address City T95206 <br /> P Code <br /> 3408 Manthey Rd . Stockton <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems , Inc. (408) 971 -2445 <br /> Mailing Address <br /> 680 Quinn Ave , San Jose 95112 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Michael Briggs <br /> Contractor I Tank Tester L(cense # ICC Certification # ICC Certification Expiration Date <br /> 485184 8033115 5/30/2019 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> VMI 6/1 /2019 <br /> VR 4/26/2019 <br /> Ili . RESULTS OF TESTING 1 SERVICING <br /> Indicate and attach the following reports If the monitoring equipment is capable of generating either. TYN NA <br /> Z Monitoring System Sef-up 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.) Z El <br /> Was damage , debris , or liquid found inside any secondary containment systems? <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications ? <br /> (If 9Jo, " 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 /> Removed Liquid from 87 STP Sump . <br /> Schrader Valves in 87/ 91 STP Sumps , Alternative Contractor to adjust Schrader valves in Disp. 41 /2 & # 9/ 10 . § <br /> 4z r <br /> JAN 0 9 2019 <br /> � e • <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspectedlserviced 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 /> s <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br /> t <br />