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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (page 1 of 6 <br /> This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment A copy of this form <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br /> USTs within 30 days of the date of the monitoring system certification. <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10468777 110/24/2018 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> ARCO am pm # 83333 <br /> Business:Site Address City ZIP Code <br /> 550 W. Val ico Ave . I Tracy 195376 <br /> lie 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 /> ContractorlTank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 4/8/2019 <br /> Monitorina System Training and Certifications i Listafiapplicable certifications. Expiration Date <br /> Veeder Root A30138 10/30/2019 <br /> VMI Va orless LDT-890 Tester # 4068 6/5/2019 <br /> Ill. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the Hollowing 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? <br /> (if Wes, " Identify the specific devices replaced and list the manufacturer and model for all replacement parts in section iV below.) 11 <br /> Was damage, debris, or liquid found inside any secondary containment systems? <br /> (if Wes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? <br /> (If 'No, " descdbe 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. 5 . � <br /> 7 01 <br /> `..,. t `� <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 /> r�--t.«' <br /> MRA a ralifrunla FmAffmmprflal Rpmdinn cvQhr m In a iripntr$ratinn IrY' a intpmaHrml r`.rvfa raw mr!7 V a Vpa N a Nn NO a Nnt wulirmt4 a <br />