Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM ( Page 1 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 /> 10180955 6/24/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> GSG GAS & FOOD <br /> Business Site Address Fs <br /> ity ZIP Code <br /> 701 E CHARTER WAY TOCKTON , CA 195206 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> AFFORDA TEST (209 ) 744-0112 <br /> Mailing Address <br /> 416 2ND ST GALT , CA 95632 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> FELIX RAMIREZ <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08 - 1740 Ex . 3/31 /20 8883072 - UT 11 /9/2019 <br /> Monitorinq S stem Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root B34976 7/7/2020 <br /> Incon 1009883708 11 /30/2020 <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 /> OX <br /> Monitoring System Set-up QX 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 IV below.) <br /> Was damage , debris , or liquid found inside any secondary containment systems? ❑ X 0 <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer' s specifications? 0 El ❑ <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 /> DISP 3-4 WAS TAGGED OUT DUE TO BEING HIT BY A CAR . <br /> JUL u 4 2019 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTI+. ENT <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 . , 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 LIST system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS = Califomia Environmental Reporting System, ID = Identification, ICC = Intemational Code Coundl, Y = Yes, N = No, NA = Not Applicable <br />