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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM <br /> I . FACILITY INFORMATION <br /> CERS ID Date : <br /> 4/26/2019 <br /> Business Name Building # <br /> Arco AmPm - Trinity <br /> Business Site Address City Zip Code <br /> 10715 Trinity Parkway Stockton <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing Test Phone # : <br /> BZ Service Station Maintenance 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 /> VR TLS 3xx= B48857 3/29/ 2020 <br /> III . RESULTS OF TESTING / SERVICING <br /> Indicate & attach the following reports if the monitoring equipment is capable of generating either. Y N N /A <br /> ® Monitoring System Set- up ® Alarm History Report <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 /> Was damage, debris, or liquid found inside any secondary containment systems ? <br /> ( If "Yes" describe what was found in section IV below . ) ❑ ® ❑ <br /> Is all monitoring equipment operational per manufacturer' s specifications? <br /> ( If "No" describe why in section IV below . ) ® ❑ ❑ <br /> IV . COMMENTS <br /> Describe how and when the issues were or will be corrected . <br /> REG <br /> JUL ) IJ19 <br /> ENVIRONMENTAL HEALTH <br /> nFRARTMENT <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 SignatureT_ _ <br /> � j <br />