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CERS = Caltomia Emvonmertal Reporting System, ID = Identtrafion, ICC = International Code Cound, Y= Yes, N = No, NA = Not Applicable UIVUCKk2KI)UNW STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page t of s) `tis form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy I 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 a enc r ulatin the USTs within 30 da s of the date of the monitoring system certification. I. FACILITY INFORMATION CERS Date of Monitoring System Certificatio 101800637 2/21/2019 Business Name (Same as Facility Name or DBA -Doing Business As) Building # GEMCO RIPON TRUCK PLAZA Business Site Address it ZIP Co 1022 S. FRONTAGE ROAD RIPON, CA 9536 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # AFFORDA TEST (209) 744-0112 Mailing Address 416 2ND ST. GALT, CA 95632 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) ZANE NIMMO Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04-1676 Ex. 3/31/19 8883064 -UT 6/1/2019 Monitoring System 1 mining and Certifications List ali applicable cerfifications.2 Ex iration Date Veeder Root A28446 9/28/2019 Incon1009843708 11/30/2020 III. RESULTS OF TESTING I SERVICING dicate and attach the following reports if the monitoring equipment is capable of generating either. ❑X Monitoring System Set-up ❑X Alarm Histo Report Y N NA Was any monitoring equipment replaced? (If "Yes. " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) ❑ ❑ Was damage, debris, or liquid found inside any secondary containment systems? "Yes, " (If describe what was found in section IV below.) ❑ 0 ❑ Is all monitoring equipment operational per manufacturer's specifications? (If "No.'describe why in section lV below.) ❑ ❑ IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I 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 2636 and all information contained herein is true and accurate. Attached to -is certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary verify that this information th and e site Ian showingthe layout of UST system is complete and accurate. UST Service Technician Signature _ CERS = Caltomia Emvonmertal Reporting System, ID = Identtrafion, ICC = International Code Cound, Y= Yes, N = No, NA = Not Applicable