Laserfiche WebLink
UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (Pagel of e) <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 />10181487 5/21/20 <br />Business Name (Same as Facifity Name or DBA-Doing Business As) Building # <br />Speedway 4612 <br />Business Site Address City ZIP Code <br />2448 W Kettleman Ln. Lodi 95242 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />Phone # <br />Service Station Systems, Inc. <br />(408) 971-2445 <br />Mailing Address <br />680 Quinn Ave., San Jose 95112 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />Brian McPheely <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />485184 <br />8822062 <br />1111/2021 <br />Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br />Veeder Root TLS 3XX 636745 11/21/2021 <br />1 Vaporless Manufacturing Inc #3803 10/2912021 <br />Red Jacket #636745 10/29/2021 <br />FE PETRO #1014303708 11/21/2021 <br />III. RESULTS OF TESTING i SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />Z Monitoring System Set-up W1 Alarm History Report <br />Y <br />N <br />NA <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 below.) <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />Z <br />❑ <br />(If "Yes,"describe what was found in section IV below) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />❑ <br />❑ <br />(If "No, "describe why in section IV b_elow.) <br />IV. COMMENTS <br />If directed to use this section, describe how and when the issues were or will be corrected. <br />R EC E i L." <br />JUN U s 9-020 <br />ENVIRONMENTAL HEALT <br />DEPARTMENT <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, ICC = International Code Council, Y = Yes, N = No, NA= Not Applicable <br />