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RECEIVED BY SJC EHD (EF) ON 8/17/2021 �Md C qko <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page t 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 /> 8/14/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> My Mini Mart <br /> Business Site Address City ZIP Code <br /> 1756 N. Wilson Way Stockton 95205 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Elite IV Contractors (209) 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr Stockton, CA 952005 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> Chris Adams <br /> Contractor!Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1001331 A, HAZ 8230218 9/1/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder-Root TLS 10/8/2021 <br /> Ill. RESULTS OF TESTING 1 SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> ❑ Monitoring System Set-up ❑Alarm History Report <br /> Was any monitoring equipment replaced? El 1:1(lf"Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section W below.) <br /> Was damage,debris, or liquid found inside any secondary containment systems? El ❑ El <br /> "Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? El 1:1 El <br /> "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 /> SR0082302 -Environmental Health Record - Sensor Functionality with Stacy Rivera <br /> Replacement of Incon Monitoring System to Veeder-Root TLS 350 <br /> Serial numbers for the new sensors <br /> 1 Annular Sensor 794390-420 SN 1437321 ( Split Tank) <br /> 2 Sump Sensors 794380-208 SN 1435958 (87) 794380-208 SN1435959 (91) <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspectecilserviced 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 thijiSk4pirmation and the site plan showing the layout of UST system is complete and accurate. <br /> UST S c nicia Signature <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=international Code Council,Y=Yes,N=No,NA=Not Applicable <br />