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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM <br /> I . FACILITY INFORMATION <br /> CERS ID Date : <br /> 16/19/2019 <br /> Business Name Building # <br /> Arco AmPm - Harney Ln <br /> Business Site Address City Zip Code <br /> 255 E Harney Ln 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 /> Contractor License # : 433159 ICC Certification #: 5244364- UT ICC Certification Expiration Date : 1/4/2021 <br /> Monitoring System Training & Certification Expiration Date <br /> VR TLS 3xx- A22883 2/27/2021 <br /> FMI LD Tester- 2906 7/8/2020 <br /> OPW- 100656 7/23/2020 <br /> III , RESULTS OF TESTING / SERVICING <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 Report <br /> Was any monitoring equipment replaced ? <br /> ( if "Yes" identify the specific devices replaced and list the manufacturer & model for all replacement parts in section IV 1:1 ® El <br /> Below) <br /> Was damage, debris, or liquid found inside any secondary containment systems? <br /> ( If "Yes" describe what was found in section IV below . ) El ® El <br /> Is all monitoring equipment operational per manufacturer's specifications? <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 /> i <br /> RECE .. <br /> ALIG <br /> DEPARTMENT <br /> V . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hearby certify that the equipment identified in this document was inspected/serviced in accordance with California Regulations, Title 23 , Division <br /> 3 , Chapter 16, Section 2638 and all information contained herein is true and accurate . Attached to this certification is information ( e. g. <br /> manufacturers' checklists, monitoring system set- up, alarm history report etc . ) necessary to verify that this information and the site plan showing <br /> the layout of UST system is complete and accurate . <br /> UST Technician Signature <br />