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UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM <br />I. FACILITY INFORMATION <br />CERS ID <br />Date: <br />11/13/2019 <br />Business Name <br />Arco <br />Building # <br />Business Site Address <br />255 E Harney Lane <br />City <br />Lodi <br />Zip Code <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing Test <br />BZ Service Station Maintenance <br />Phone #: <br />916-371-2380 <br />Business Mailing Address <br />1401 Triangle Ct., West Sacramento, CA 95691 <br />Name of UST Service Technician <br />Darnell Smith <br />Contractor License #: 433159 ICC Certification #: 8709494 ICC Certification Expiration Date: 12/21/2019 <br />Monitoring System Training & Certification Expiration Date <br />III. RESULTS OF TESTING / SERVICING <br />Indicate & attach the following reports if the monitoring equipment is capable of generating either. <br />❑ Monitoring System Set-up ❑ Alarm History Report <br />Y <br />N <br />N/A <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 <br />Below) <br />❑ <br />❑ <br />❑ <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />(If "Yes" describe what was found in section IV below.) <br />❑ <br />❑ <br />❑ <br />Is all monitoring equipment operational per manufacturer's specifications? <br />(If "No" describe why in section IV below.) <br />❑ <br />❑ <br />❑ <br />IV. COMMENTS <br />Describe how and when the issues were or will be corrected. <br />Arrived on site to test vac sensor floats on S1, S2, S3, S4, S6 and overfill testing. <br />RECEIVED <br />NOV 1 8 2019 <br />ENVIRONMENTAL HEALTH <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 Signa'Ur / <br />/_— <br />