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RECEVED <br /> UNDERGROUND STORAGE TANK ,J U L ) 7_ o <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of s <br /> Fimnust <br /> is form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form <br /> be provided to the UST owner or operator. The owner or operator must submit a copy of this fo r\ � �cy, gegylati4tkiQ <br /> TH <br /> STs within 30 days of the date of the monitoring system certification. K! l ! A I # X11 <br /> I. FACILITY INFORMATION ' ' ` <br /> CERS ID Date of Monitoring System Certification <br /> 10422475 07/02/2020 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> Yosemite Avenue Arco Am Pm <br /> Business Site Address City ZIP Code <br /> 1711 E . Yosemite Ave. I Manteca 195336 <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 04/05/2021 <br /> Monitoring System Training and Certifications List all a iicable certifications. Ex iration Date <br /> Veeder Root A30138 10/05/2021 <br /> VMI Va oriess LDT-890 Tester # 4068 06/13/2021 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports /f the monitoring equipment Is capable of generating either. Y N NA <br /> ® Monitoring System Set-up ® 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? 10 0 0 <br /> (if "Yes, " describe what was found In section IV below.) <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 /> Small amount of water was found in all fill sumps . <br /> Water was removed and placed into a 55 gal Haz drum located on site <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 /> rFRR a r alifnrnia Frn imnroantal RannHinn _quatmn In a kbn"raHnn irY: = Ii Zmaler"larxvirtr1l V a Yaa N = Nn NA a Nn! awArahla <br />