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UNDERGROUND STORAGE TA K - - <br /> rte_ <br /> MONITORING SYSTEM CERTIFICATIO q FORM <br /> I . FACILITY INFORMATION <br /> CERSID Date : <br /> 11 $/ 2018 <br /> Business Name Building # <br /> Arco Victor <br /> Business Site Address City Zip Code <br /> 880 E Victor Rd , Lodi <br /> II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing Test Phone # : <br /> BZ Service Station Maintenance 916 -371-2380 <br /> Business Mailing Address <br /> 1401 Triangle Ct . , West Sacramento, CA 95691 <br /> Name of UST Service Technician <br /> Rhome Desbiens <br /> ICC Certification # : 5244364 ICC Certification Expiration Date : 1/5/ 2019 <br /> Contractor License # : 433159 <br /> Expiration Date <br /> Monitoring System Training & Certification <br /> Veeder Root TLS 3xx- A22883 3/ 1/ 2019 <br /> 7/8/2020 <br /> VI LD Tester- 2906 <br /> M <br /> Ill . RESULTS OF TESTING / SERVICI G <br /> Indicate & attach the following reports if the monitoring equipment is capable of generating either. Y N N /A <br /> ® Monitoring System Set-up ® Alarm History Re ort <br /> Was any monitoring equipment replaced ? <br /> El <br /> ( if "Yes" identify the specific devices replaced and list the manufacturer & model for all replacement parts in section IV <br /> Below ) <br /> Was damage, debris, or liquid found inside any secondary containment systems? 0 ® El <br /> ( If "Yes" describe what was found in section IV below . ) <br /> Is all monitoring equipment operational per manufacturer' s specifications? ® ❑ 11 <br /> ( If " No" describe why in section IV below . ) <br /> IV . COMMENTS <br /> Describe how and when the issues were or will be corrected . <br /> V . CERTIFICATION BY UST SERVICE TECHNICIAN COND CTING THIS TESTING <br /> I hearby certify that the equipment identified in this document was inspected/serviced in accorda ice with California Regulations . Title 23, Division <br /> 3, Chapter 16, Section 2638 and all information contained herein is true and accurate . Attal . 'r,ed tc this certification is information ( e . ge <br /> manufacturers' checklists, monitoring system set- up, alarm history report etc . ) necessary to verif that this information and the site plan showing <br /> the layout of UST system is complete and accurate . <br /> UST Technician Signature <br />