Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM <br /> I. FACILITY INFORMATION <br /> CERS ID Date: <br /> 6/16/2020 <br /> Business Name Building# <br /> Arco AmPm- Harney Ln <br /> Business Site Address City Zip Code <br /> 255 E Harney Ln Lodi <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing Test Phone#: <br /> BZ Service Station Maintenance 916-371-2380 <br /> Business Mailing Address <br /> 1401 Triangle Ct.,West Sacramento,CA 95691 <br /> Name of UST Service Technician <br /> Rhome Desbiens <br /> Contractor License#:433159 ICC Certification#: 5244364-UT ICC Certification Expiration Date:1/4/2021 <br /> -Monitoring System Training&Certification Expiration Date <br /> VR TLS 3xx-A22883 2/27/2021 <br /> VMI LD Tester-2906 7/8/2020 <br /> OPW-100656 7/23/2020 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate&attach the following reports if the monitoring equipment is capable of generating either. Y N N/A <br /> ®Monitoring System Set-up ® Alarm History Report <br /> Was any monitoring equipment replaced? <br /> (if"Yes"identify the specific devices replaced and list the manufacturer&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? E El El <br /> (If"No"describe why in section IV below.) <br /> IV. COMMENTS <br /> Describe how and when the issues were or will be corrected. <br /> Pumped small amount of water from 87 fill sump and DSL fill sump. <br /> 91 STP sump sensor inop.Replaced 208 sensor with new sensor,retested,passed. Et, !, <br /> i <br /> 87 fill sump sensor inop. Replaced 208 sensor with new sensor,retested,passed. ,. ,, <br /> Lj <br /> UDC 13/14 brine sensor inop.Replaced 304 sensor with new sensor,retested,passed. JUN 2 4 2026 <br /> UDC 15/16 brine sensor inop.Replaced 304 sensor with new sensor,retested,passed. <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hearby certify that the equipment identified in this document was inspected/serviced in accordance with California Regulations.Title 23,Division <br /> 3,Chapter 16,Section 2638 and all information contained herein is true and accurate.Attached to this certification is information(e.g. <br /> manufacturers'checklists,monitoring system set-up,alarm history report etc.)necessary to verify that this information and the site plan showing <br /> the layout of UST system is complete and accurate. <br /> UST Technician Signature <br />