Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM of this form <br /> FThsformmust be used to document testing and servicing of underground storage tank (UST) monitoring equipment. Acopyst 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 certifications <br /> FACILITY INFORMATION <br /> Date of Monitoring System Certification <br /> CERS ID 8 - 11 -20 <br /> 10180781 Building # <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) <br /> United Pacific # 5447 it ZIP Code <br /> Business Site Address Stockton 95210 <br /> 1469 East Hammer Lane <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification ( 916 ) 991 - 1100 <br /> a CTGRS <br /> M <br /> ailingAddress <br /> 5444 Dry Creek Road ; Sacramento , Ca . 95838 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br /> Garrett Warren ICC Certification Expiration Date <br /> Contractor/Tank Tester License ICC Certification ## 8185019 9 -20 -21 <br /> CSLB#803616 Expiration Date <br /> Monitoring System Training and Certifications (List all applicable certifications.) 1 -21 -21 <br /> 642126 Veeder- Root 5 - 3 -22 <br /> VMI LDT- 890 Tester/ 43822 <br /> III . RESULTS Om ntE's capable of genleratvng either. �( N NA <br /> Indicate and attach the following reports if the monitoring eq p 0 Alarm History Report <br /> El Monitoring System Set-up ❑ <br /> Was any monitoring equipment replaced? <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and 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.) Iva COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be S@IISOrS that failed t0 orlglnall�/ alram . <br /> Replaced T- 1 91 & T-4 Diesel STP VR-208 sump <br /> Replaced T- 3 87 tank annular Veeder Root 409 sensor that broke trying to remove form annular . <br /> v, CERTIFICATION BY UST SERVICE TECjt HNICIAN CONDUCviiiTceING THclaI IS TESTINwvvGee ff <br /> I hereby certify that the equipmentadter 16 sect o'n 2638 and all nformationdcont in d 'herein is true anld thh accaa <br /> u' rate ' aAttached to <br /> Regulations , title 23 , division 3 , ch p , <br /> this certification is information (e . g . , manufacturers ' checklists , monitoring system set-up , alarm history report) etcnnecessa <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 /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not applicable <br />