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6 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (page 1 of 0) <br /> Fformbe used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form <br /> d 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 /> 10746523 2/19/2019 <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. I Escalon 195320 <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 all applicable certifications. Ex Iration Date <br /> Veeder Root A30138 10/30/2019 <br /> VMI Va orless LDT-890 Tester # 4068 6/5/2019 <br /> 111. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the hollowing reports ff 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? <br /> (if No, " describe why in section IV below.) C9 rEl 0 <br /> N. COMMENTS <br /> if directed to use this section, describe how and when the issues were or will be corrected. <br /> Brine sensors 794380-304 were replaced in Dispenser 1 &2 and Vent Box <br /> I1111A R " <br /> ENVIOL) I 4L 14 <br /> v <br /> " L , <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 oJILIST system Is complete and accurate. <br /> UST Service Technician Signature <br /> MRS = railrnr 1A FminmunorMal RanrvHm AvQforn to = kim"firafinn irr: = IntamAnnW rfvia rJv aril Y = Ypc N = Nn NO arxilLmNo <br />