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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page I of 6) <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 /> 10402351 110/23/2018 <br /> Business Name(Same as Facility Name or DBA—Doing Business As.) Building# <br /> ARCO am/pm#83230 <br /> Business Site Address City ZIP Code <br /> 1340 W. Colony Rd. I Ripon 195366 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Diamond Petroleum Services, Inc. (925)470- 0803 Ext. <br /> Mailing Address <br /> 3619 King Ct. Antioch, CA 94509 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification.) <br /> Guadalupe Sanchez <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 4/8/2019 <br /> Monitorinq System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A30138 10/30/2019 <br /> VMI Va orless LDT-890 Tester#4068 6/5/2019 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> ®Monitoring System Set-up ®Alarm History Report Y N NA <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.) 0 ED El <br /> Was damage,debris,or liquid found inside any secondary containment systems? <br /> (If'Yes,"describe what was found in section IV below.) El <br /> Is all monitoring equipment operational per manufacturers specifications? ® 0 11 <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 <br /> NTA <br /> t RT. <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspectediserviced 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 /> rFRC a ralifvnia FnuirrwnarvW RannrBnn Cua4nm in=44vdiRrailnn irr.=Iniamatinnai r"ia r.N inril V=Vac N=Nn NO=Nnt ar"irahlp <br />