Laserfiche WebLink
.Jun, 26. 2020 3:39PM Donl ee Puma Co No, 4053 P. 2 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page i of 6) <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy of this form <br /> 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 <br /> USTs within 30 days of the date of the monitoring system certlficatlon. <br /> _ I. FACILITY INFORMATION <br /> CERS ID,w� Qate of Monitoring System Certification <br /> -a <br /> Business Name(Same as Facility Name or DBA—Doing Business As.) Building# <br /> 1 M <br /> Buslness Site Ad ress City ZIP Code <br /> U-Z LoC. KA r <br /> II. JUNDERG UND ORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Donlee Pump Company (209) 537 - 9396 Ext. <br /> Mailing Address <br /> 2825 Railroad Ave. Ceres, CA. 95307 <br /> Name of UST Service Teehnlclan Performing the Certification(Print as shown on the ICC Certiticalion.) <br /> Contractorfrank Tester License# ICC Certification# �^ ICC Certification Expiration Date <br /> 5899gyo <br /> Monitorin System—Training and Certifications list off applicable certifications.) Ex ballon Date <br /> trEi✓b�1t —q,v f C Z,r16Z3 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach file following reports If the monitoring equipment is capable of generating either. Y N NA <br /> Monitoring System Set-up �larm history Report <br /> Was any monitoring equiprTient replaced? D El <br /> (if"Yes,°lden(V the spocibc 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 containmanl sys(ems? El El <br /> (if`Yes,"describe what was found in section!V below.) <br /> Is all monitoring equipment operational per manufacturer's speciricalions? ❑ 0 <br /> (lf"No,°describe why in section W below.) <br /> _ IV. COMMENTS ^ <br /> Udireoted to use this ssollon,describe how and whan the issues were or will be corrected. <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment Identified In this document was inspectedlserviced 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 hls infonpation and the site plan showing the layout of UST system Is complete and accurate. <br /> UST Sere ch ' ` nature <br /> CERS=Callfomia Environmental ReporUnm System,ID=IderMciltion,ICC=InWmaforW Code Council,Y■Yes,N-No,NA-Not applicable <br />