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7 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (page t of e) <br /> Fform be used to document testing and servicing of underground storage tank (UST) monitoring equipment A copy of this form <br /> ed 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 /> 10182265 10/17/2018 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> ARCO AM PM # 82602 <br /> Business Site Address City ZIP Code <br /> 2430 Joe Pombo Pkwy Tracy 195376 <br /> 11. 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 /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 4/8/2019 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A30138 10/30/2019 <br /> VMI Va orless LDT-890 Tester # 4068 6/5/2019 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports If 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? 10 11 0 <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? 11 ® 13 <br /> (If Test " describe what was found in section IV below.) <br /> is all monitoring equipment operational per manufacturer's specifications? ® 0 <br /> (If "No, " describe why in section IV below.) <br /> Iv. COMMENTS <br /> if directed to use this section, describe how and when the issues were or will be corrected. <br /> Annular sensor was replaced "like for like" in the 91 /87 Syphon split tank . <br /> Model # 794390409 Serial # 1080909. Inspector on site . <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 of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> [`FRR c f.alifAmia Fm�inwimirNal Ruwfirfn Svckxr+ in a 4lantiaralir+n IrY: » Intwnaftn+al rlvin r'.rv "rJl Y cYt+c N c Nn NO a NrtitanNlrahlo <br />