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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page I 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 /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10182265 10/17/2019 <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 95376 <br /> II. 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 04/05/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A30138 10/05/2021 <br /> VMI Va orless LDT-890 Tester#4068 06/12/2021 <br /> Ill. 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? <br /> (if'Yes,"idendly 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? I] ® 13 <br /> (if'Yes,"describe what was found in section 1V 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 /> 1 cENVIRUNMEN _ <br /> DAL <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`FRC o rafifrvnia FrnrirrwnoMal Rarxvfim Cvcfan in=kiw*fir_-4;m irr c b*mralimal rrrla rrw,nrnl V=vac N=Nn Na=Nrd amJ'irahla <br />