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Appendix VI RECEIVED <br /> Underground Storage Tank <br /> Monitoring System Certification Form OCT 18 2022 <br /> TYPE OF ACTION ❑ Installation Repair x12 Month <br /> 1. ' FAl A <br /> 1111FQRIVIATI > 1 <br /> NTAL HEALTH <br /> III <br /> aEpATMEITad <br /> ACILIfiY <br /> =CERSCertification Date <br /> 10/21 /2021 <br /> Facility Name <br /> ARCO AM PM # 82602 <br /> Facility Address City ZIP Code <br /> 2430 Joe Pombo Pkwy Tracy 95376 <br /> SEIviCE Tl)"CHN#CIAt� INF©� VAAT"�C31�1 <br /> I <br /> Adtt. <br /> :� � �r a <br /> a= . 1 I <br /> I Ad <br /> Company Performing the Certification Phone <br /> Iq <br /> Diamond Petroleum Services , Inc. ( 925) 470 -0803 <br /> Mailing Address <br /> 3619 King Ct Antiioch , CA 94509 <br /> Service Technician Performing Test <br /> Guadalupe Sanchez <br /> Contractor/Tank Tester License Number <br /> 1005444 <br /> ICC Number <br /> 5250451 ICC Expiration Date <br /> 04/01 /2023 <br /> jFI <br /> AIN tNG ASID GERTII"IAT'II If <br /> :. . _ :: <br /> Manufacturer and Test Equipment Training Certifications <br /> Expiration Date <br /> Veeder-Root ATG Technician # A30138 10/29/2023 <br /> VMI Vaporless LDT-890 Tester # 4068 06/ 13/2023 <br /> .. . GI✓Rt"Ii 'kkATt tY SIR'VICI TA A.�Gi1lIAAI?I E31wIf R1�IGTIIW T '1 <br /> I hereby certify that the monitoring system is operational in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2638; that required supporting documentation is <br /> attached; and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 10/21 /2021 17 <br /> 5Iifl14 NITiC� I�IN+ : Y . . T . . ANS R , faRAllljlllll +l ; IT <br /> « ... <br /> - = f <br /> CERS = California Environmental Reporting System , GPH = Gallons Per Hour, ID = Identification , <br /> ICC = International Code Council ,` LLD = Line Leak Detector, NA = Not Applicable , SW = Single- <br /> Walled , UDC ` = Under DispenserContainment , UST = Underground Storage Tank , <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />