COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Pagel of 6) This form must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy of this form 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 USTs within 30 days of the date of the monitoring system certification . I . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10181497 5/28/2020 Business Name (Same as Facility Name or DBA-Doing Business As) Building # SRH - FOOD & GAS Business Site Address City ZIP Code 749 E . CHARTER WAY STOCKTON , CA 195206 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # AFFORDA TEST (209 ) 744 - 0112 Mailing Address 416 2ND STREET GALT , CA 95632 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) ZANE NIMMO Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04 - 1676 Ex . 3/31 /22 8883064- UT 6/ 1 /2021 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder Root A28446 10/2/2021 Incon 1009843708 11 /30/2020 III . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA XMonitorin System Set-up ❑X Alarm Histo Report Was any monitoring equipment replaced ? ❑ N El(If "Yes, " identify the specific 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? El (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications ? (If "No, " describe why in section IV below.) IV. COMMENTS i If directed to use this section, describe how and when the issues were or will be corrected. I I I I i I. 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 CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable