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RECEIVED BY EHD: <br /> UNDERGROUND STORAGE TANK 7/27/2021 <br /> MONITORING SYSTEM CERTIFICATION FORM (Page (received via Crompco Vault Portal) <br /> This form must be used to document testing and servicing of underground storage tank(US 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 <br /> local 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 /> UNKOWN 1 7/11/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) Building# <br /> Fed Ex Ground <br /> Business Site Address City: Zip: <br /> 120 S Hansen Road Tracy 95304 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> TANKNOLOGY INC. (800) 800-4633 Ext. <br /> Mailing Address <br /> 11000 N. Mopac Expressway#500, Austin, TX 78759 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br /> Jesus Saldivar <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/13/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> ICC CA UST Service Technician 8361393 06/13/2021 <br /> Veeder Root VR Level 4 B45334 04/28/2021 <br /> VMI TLDT-5000 Tester 3802 11/20/2019 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> W Monitoring System Set-up P_/ 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.) <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? Wo r- <br /> (If"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 /> 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 <br /> to this certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) <br /> necessary 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 /> A116-ela— <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />