Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of s) <br /> Thi7form <br /> t be used to document testing and servicing of underground storage tank (UST) monitoring equipment, A copy <br /> of tust be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> a etin the USTs within 30 da s of the date of the monitorin s stem certification . <br /> I . FACILITY INFORMATION <br /> CERS ID 10181229 :::]:Date of Monitoring System Certification <br /> 24/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Shell/Tesoro <br /> Business Site Address City ZIP Code <br /> 35 N . Cherokee Ln . Lodi 95240 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Service Station Systems (408) 971 m2445 <br /> Mailing Address <br /> 680 Quinn ave San Jose Ca, 95112 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Brian McPheely <br /> Contractor t Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /9/2019 <br /> Monitoring System Training-and Certifications List all applicable certifications. Expiration Date <br /> VR B36745 2/27/2020 <br /> VMI 111 /29/2019 .... <br /> I <br /> Ili , RESULTS OF TESTING / SERVICING <br /> indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> ® <br /> Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced ? ® [l El <br /> (if "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section 1V below) <br /> Was damage, debris , or liquid found inside any secondary containment systems? El 0 El <br /> (If "Yes, " describe what was found in section IV below.) <br /> is all monitoring equipment operational per manufacturer's specifications ? z 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. v <br /> Replaced the 87 annular sensor (VR 794390-420) - Retested Passed , <br /> FEB 0 �05 201 <br /> ENVIRONMENTAL HALT .I <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 = Calftnia Environmental Reporting System, ID = identification, iCC = international Code Council, Y = Yes, N = No, NA = Not Applicable <br /> i <br /> i <br />