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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM Page 1 of 6 FUSTs must be used to document testing and servicing of underground storage tank (UST) monitoring equipment A copy of this form rovided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the in 30 days of the date of the monitoring system certification. I. FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10181249 12/21 /2019 Business Name (Same as Facility Name or DBA — Doing Business As.) Building # ARP Mini Mart Mobil Business Site Address City ZIP Code 25775 S . Patterson Pass Rd . Tracy 195376 Il. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Diamond Petroleum Services, Inc. (925) 470 - 0803 Ext, Mailing Address 3619 King Ct . Antioch , CA 94509 Name of UST Service Technician Performing the Certification (Print as shown on the /CC Certification.) Guadalupe Sanchez Contractorirank Tester License # ICC Certification # ICC Certification Expiration Date 1005444 5250451 4/8/2019 Monitoring System TraininA and Certifications fist all applicable certifications. Expiration Date Veeder Root A30138 10/30/2019 VMI Va orless LDT-890 Tester # 4068 6/5/2019 III. RESULTS OF TESTING/SERVICING Indicate and attach the following reports If the monitoring equipment is capable of generating either. Y N NA ® Monitoring System Set-up ® Alarm History Report Was any monitoring equipment replaced? 0 ® 0 (if "Yes, identify the spec devices replaced and list the manufacturer and model for all replacement parts in section IV below.) Was damage, debris, or liquid found inside any secondary containment systems? (If "Yes, " describe what was found in section iV below.) Is all monitoring equipment operational per manufacturer's specifications? 0 O 0 (if "No, " describe why In section IV below.) IV. COMMENTS if directed to use this section, describe how and when the issues were or will be corrected. t E IV, A F, r S e V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2638 and all information contained herein is true and accurate. Attached to this certification Is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature t`FRC = r`AWvnla Fm&tmmmnlal Poem innAmfom In = 4lan"fir=Hm ICY: = Intm=HnnAl MAP r av mro9 V = Vac N = Nn N6 = NM anriirahb