INSTALL_2019 - Laserfiche WebLink

Home Browse Search

19204310.5 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM(Page t of 6) This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy 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 agency regulating the USTs within 30 days of the date of the monitoring system certification. I. FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10339507 1 11/27/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Building# Arco 7049 Business Site Address City ZIP Code 800 E Kettleman Lane Lodi 195240 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone# Gettler-Ryan Inc. (925) 551-7555 Mailing Address 6805 Sierra Court, Suite G, Dublin, CA 94568 Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certlfrcatlon) Elodio Sanchez Contractor!Tank Tester License# Certification# ICC Certification Expiration Date ICC 220793 8887127 6/4/2020 Mon1toring System Training and CerUficatlons List all applicable cerlifications. Expiration Date Veeder Root TLS3XXX Tech Ceti B41204 7/5/2020 VMI Line Leak#3200 12/3/2020 — VM I 2/3/2020VMI LDT-890 Leak Detector Tester#3201 12/3/2020 III. RESULTS OF TESTING 1 SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA x Monitoring System Set-up x Alarm History Report Was any monitoring equipment replaced? Q (If'Yes,"Identify the specific devices replaced and list the manufacturer and model for all replacement parts In section IV below.) Was damage,debris,or liquid found inside any secondary containment systems? (If"Yes,'describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? (1t'No,"describe why in sactlon IV below.) N El El IV. COMMENTS ll directed to use this section,describe how and whop the Issues were or will be corrected. RECEIV DEC i, 7 Zoo ENVIRONMENTAL HEAF DEPARTS!,,FNT V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment Identified In this document was inspected/serviced in accordance with California Code of Regulations,Title 23,Division 3,Chapter 16,Section 2638 and all Information contained herein Is true and accurate. Attached to this certification Is information(e.g.,manufactursUolchocklists,monitoring system set-up,alarm history report,etc.) necessary to verify that this Information and slte plana n th a out of UST system is complete and accurate. UST Service Technician Signature CAS&A CERS=C liibmia Ernironmental Reporting System,10-Identification,ICC=triftriatlorel Code Card,Y=Yes,N=No,NA=Not Appic"