Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page t 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 /> 1. FACILITY INFORMATION <br /> CERS ID —[:Dale of Monitoring System Certification <br /> 10181238 7/ 15/2019 <br /> Business Name (Same as Facility Name or DBA=Dorng Business As) Budding # <br /> Arco 5450 _ <br /> Business Site Address City ZIP Code <br /> 1617 W , Fremont Stockton 95203 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Gettler- Ryan Inc. ( 925 ) 551 -7555 <br /> Mailing Address <br /> 6805 Sierra Court , Suite G , Dublin , CA 9456 $ <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> David Rouse <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 6/28/2020 <br /> Monitoring System Training and Certifications List all applicable certifications ) Expiration Date <br /> Veeder Root Tech Cert # 644848 7/2/2020 <br /> VMI Leak Detector Tech Cert #3625 9/7/2020 <br /> VMI LDT-890 Leak Detector Tester Tech Cert #3626 9/7/2020 <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 /> x <br /> Monitoring System Set- up0 Alarm Report <br /> Was any monitoring equipment replaced ? Q <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? o Q <br /> (If "Yes, " describe what was found in section IV below ) <br /> Is all monitoring equipment operational per manufacturer 's specifications? O <br /> (If "Nov " 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 /> A , <br /> 3 e <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspectediserviced 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 . , manufacturersc ecklists , monitoring system set- up , alarm history report, etc .) necessary <br /> to verify that this information and the site pla4sho g the layout of UST system is corn lete and accurate , <br /> UST Service Technician Signature _ <br /> CERS = California Environmental Reporting System. ID = ldent lication. ICC = International code Council. Y a Yes N = No NA = Not Applicable "' <br />