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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel of 6) <br /> FforffTtn be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form <br /> ed to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br /> days of the date of the monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181463 13/6/2020 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> Village West Marina <br /> Business Site Address City ZIP Code <br /> 6649 Embarcadero Drive I Stockton 195219 <br /> lie UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification 7i(925) <br /> hone # <br /> Diamond Petroleum Services , Inc. 470 - 0803 Ext. <br /> Melling 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/rank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 04/05/2021 <br /> Monitoring System Training and Certifi List all applicable certifications. Expiration Date <br /> Veeder Root A30138 10/05/2021 <br /> VMI Va orless LDT-890 Tester # 4068 06/12/2021 <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 /> ® 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? <br /> (if "yes, " describe what was found In section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ® o 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 /> 1 I z <br /> NVI i E 'y ff As i l <br /> DEPM-1 <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 /> f FRR = CaGfnn+la Frwirrwnnanlal Ronnrfinn fire}nni in = Wanffir..2ffm M. = 1rNwnatlnnal r"fP r`.ry tn6I Y = Yac N = Nn NA = " anrdimNA <br />