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C � <br /> 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 /> 1. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181463 3/6/2019 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> Village West Marina <br /> Business Site Address Ciry ZIP Code <br /> 6649 Embarcadero Drive Stockton 95219 <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 4/8!2019 <br /> Monitoring System Training and Certifications Ust a# a !feeble certifications. Expiration Date <br /> Veeder Root A30138 10/30/2019 <br /> VMI Va orless LDT-890 Tester # 4068 6/5/2019 <br /> Ill. 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 speck 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 /> jIs all monitoring equipment operational per manufacturers specifications? <br /> (If °No, " describe why in section iV below.) ED Oj 0 <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the Issues were or will be corrected. <br /> i <br /> s <br /> 3 <br /> i <br /> D1 � <br /> E <br /> I <br /> EALT <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 U system is complete and accurate. <br /> UST Service Technician Signature <br /> i <br /> f jd*wT Sa FmArrwmvwdW Rmww*nn Au%fPm in = kbMiflnafinn KY: a b4rtanwfinnsd rn4+ Cam inn! V a Voa N Nn NO a Nnf annHrallo <br />