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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form 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 USTs within 30 days of the date of the monitoring system certification. I . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10761034 14/8/2019 Business Name (Same as Facllity Name or DBA — Doing Business As.) Building # ARCO am/pm # 83831 Business Site Address City ZIP Code 1904 Daniels St . I Manteca 195337 Il. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Diamond Petroleum Services , Inc. (925) 470 - 0803 Ext. Mailing Address 3619 King Ct . Antioch , CA 94509 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) Guadalupe Sanchez Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date 1005444 5250451 4/5/2021 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder Root A30138 10/30/2019 VMI Va orless LDT-890 Tester # 4068 6/5/2019 III . RESULTS OF TESTING/SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA E Monitoring System Set-up E Alarm History Report Was any monitoring equipment replaced? (If `Yes, " identify the speck devices replaced and list the manufacturer and model for all replacement parts in section IV below.) Was damage, debris , or liquid found inside any secondary containment systems? 13 E ❑ (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? (if "No, " describe why in section iV below.) IV. COMMENTS if directed to use this section, describe how and when the issues were or will be corrected. The UDC sensor " like for like" 794380-208 was replaced on dispenser 1 &2 V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations, title 23, division 3 , chapter 16, section 2638 and all information contained herein is true and accurate. Attached to this certification is information (e.g . , manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature r.FRS = rAifnmia Fnvinvmuwtf: 1 RPmrfim AuQtnm in = Wnlifff%.At n irr = intpmnfirvud rwia ram irdii V = VPc N = Nn NA o Nnt arudirahiP