Laserfiche WebLink
f <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6 <br /> FTh1sform must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form <br /> 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 /> within 30 days of the date of the monitoring system certification. <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10422475 16/14/2019 <br /> Business Name (Same as Facility Neme or DSA — Bing Business As.) Building # <br /> Yosemite Avenue Arco Am Pm <br /> Business Site Address City ZIP Code <br /> 1711 E . Yosemite Ave . I Manteca 195336 <br /> IL 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 (Pdntas shown on the ICC Certification.) <br /> Guadalupe Sanchez <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 4/5/2021 <br /> Monitorina System Trainin and Certifications Ust all applicable cel ficallons. Expiration Date <br /> Veeder Root A30138 10/30/2019 <br /> VMI Va orless LDT-890 Tester # 4068 6/13/2021 <br /> VMI Mechanical Leak Detector Installer # 4067 6/13/2021 <br /> III. 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? 10 E3 0 <br /> (if 'Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section W below.) <br /> Was damage, debris, or liquid found inside any secondary containment systems? ® 11 ❑ <br /> (if Wes, " 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 /> N. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> The 87 PLLD was replaced "like for like" model 8484 in the 87 Master tank. <br /> Water was found in all fill sumps. <br /> Water was removed and placed into a 55 gal HAZ drum located on site. <br /> The 91 annular sensor failed to activate an audible and visual alarm when tested . <br /> The 91 annular sensor needs to be replaced <br /> H <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 FRR f aiNnmia FrndrrvunwMal Rnnnrfinn CvaMm IT1 a kfoMiRraHnn rfY Intwmafirva! f rx#a f ry �nr9 Y c Yc¢ N a Nn NA = Not anrAhmtda <br />