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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM <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 /> 10182249 01 /03/2019 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> VPP Fresno Ave <br /> Business Site Address CityZIP Code <br /> 1524 Fresno Ave Stockton 195206 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification one # <br /> ( 916 ) 991 - 1100 <br /> - CGRS <br /> SOLUTIONS DEUIVEnrD <br /> Mailing Address <br /> 5444 Dry Creek Road ; Sacramento , Ca . 95838 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br /> Garrett Warren <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB#803616 SWRB#06 - 1672 18185019 T10 -2 -2019 <br /> Monitoring System Training and Certifications (List all applicable certifications) Expiration Date <br /> B42126 Veeder-root 1 -23-2019 <br /> VMI LDT-890 Tester/ #3822 4-30-2020 <br /> I11 . RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> El Monitoring System Set-up EI 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 ❑ Irl below.Was damage, debris, or liquid found inside any secondary containment systems? 13(If "Yes, " describe what was found in section IVbelow.) <br /> Is all monitoring equipment operational per manufacturer' s specifications ? ❑ <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 /> —r <br /> Eb 201 11 <br /> El t � � q <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 is co plete and accurate . <br /> UST Service Technician Signature <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not applicable <br />