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I <br />UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) I <br />This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form <br />must 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 <br />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 />3/12/2020 <br />Business Name (Same as Facility Name or DBA — Doing Business As.) <br />Shell 1-5 <br />Building # <br />Business Site Address <br />717 W Eighth St <br />City <br />Stockton <br />ZIP Code <br />95206 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />Pinnacle Fuel Compliance <br />Phone # <br />(408) 206 - 9840 Ext. <br />Mailing Address <br />P.O. Box 32849 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br />Jeff Conger <br />Contractor/Tank Tester License # <br />90-1116 <br />ICC Certification # <br />1081782 <br />ICC Certification Expiration Date <br />1/24/21 <br />Monitoring System Training and Certifications (List all applicable certifications.) Expiration Date <br />Veederoot level 4 1/22/21 <br />III. RESULTS OF TESTING/SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />Report Y N NA <br />Monitoring System Set-up 4 Alarm History <br />Was any monitoring equipment replaced? <br />(If "Yes," identify the specific devices replaced and fist the manufacturer and model for all replacement parts in section IV below.) MI • <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />(If "Yes," describe what was found in section IV below.) <br />r • • <br />Is all monitoring equipment operational per manufacturer's specifications? <br />(If "No," describe why in section IV below.) II M <br />IV. COMMENTS <br />If directed to use this section, describe how and when the issues were or will be corrected. <br />Inspector Paul Nso on site. <br />A small amount of liquid was found in UDC 7/8, it was removed. <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 />-- <br />,--__/' /--4,--7.--, — <br />Cr <br />CERS = California Enviromental Reporting System, ID = Identification, ICC = Intonational Code Council, V = Yes, N = No, NA= Not applicable