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p UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FOR (Page 1 of 6) FThlsorm must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the within 30 days of the date of the monitoring system certification. 1 . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10156057 05-20-2019 Business Name (Same as Facility Name or DBA — Doing Business As.) Building # UPS Business Site Address City QIP Code 1532 North Broadway. I Stockton 95205 Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # R1 Stevens Co . (510) 435 - 6249 Ext . Mailing Address P . O Box 361 San Leandro , Ca . 94577 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) David Pereira Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date R , L Stevens Col 415807 5240739-UT 05- 18-2020 Monitoring System Training and Certifications List all ap2ficabla certifications. Ex iration Date Veeder Root 02120 Service Tech 05120 Va orless UD Tester 06/ 19 III. RESULTS OF TESTINGiSERViCiNG indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA ® Monitoring System Set-up 0 Alarm History Report Was any monitoring equipment replaced? El ® El (If `Yes, " identify the speck devices replaced and list the manufacturer and model for all emplacement parts in section IV below.) Was damage, debris , or liquid found inside any secondary containment systems? 0 (if "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? (It "No, " describe why in section iV below.) IV, COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. RECEIVED I ) I : 'A IZr1 ' i 1 E N 1, V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING 1 hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations, title 23, division 3 , chapter 16, section 2638 and all information contained herein is true and accurate. Attached to this certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc .) necessary to verify that this information gir r a si plan showing the layout of UST system is complete and accurate. UST Service Technician Signature 7: CERS = California Environme nU P4porting System, IDs Identification, ICC = fivierriational Code Council, Y = Yes, N = No, NA = Not applicable