Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel of 6) <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy <br /> 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 <br /> agency regulating the 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 /> 10169775 7 <br /> 12/19/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> Colonial Energy#40138 <br /> Business Site Address City ZIP Code <br /> 14000 Highway 88 Lockeford 195237 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Walton Engineering, Inc. (916) 372-1888 <br /> Mailing Address <br /> P.O. Box 1025, West Sacramento, CA 95691 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the/CC Certification) <br /> Max Hines, Ray Hernandez <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 617238 8750053 10/24/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder-Root <br /> Va orless -VMI <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 /> 0 Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced? ❑ ❑X ❑ <br /> (If"Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section lV below.) <br /> Was damage,debris, or liquid found inside any secondary containment systems? A ❑ ❑ <br /> (If"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ❑X FJ ❑ <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 /> Removed small amount of liquid from Diesel sump and placed in on site HAZ drum dated 12/19/2019. <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 /> CERS=Califomia Environmental Reporting System,ID=Identification,[CC=International Code Council,Y=Yes,N=No,NA=Not Applicable <br />