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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 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 /> 10746523 02/19/2020 <br /> Business Name(Same as Facility Name or DBA—Doing Business As.) Building# <br /> Pershing Holdings Inc. <br /> Business Site Address City ZIP Code <br /> 1329 Escalon Ave. Escalon 95320 <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 /> Contractorfrank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 04/05/2021 <br /> Monitoring System Training and Certifications 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. <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.) 11 <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? <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 /> Found small amount of residue inside UDC 7&8. Cleaned UDC. Inspector on site. <br /> y; <br /> ANT <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 Califomia 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 /> r F1M=r`.sJNnmla FrwirmmantxI PP vvfm RvQtPm In=kim ifir%&Im lr r=IntamaHnnl r�vin rim vrif V=Voa N=Nn NA=Nrd nr"rat <br />