COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page 1 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 10181411 1 /24/19 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Tracy Blvd Shell & Mini Mart Business Site Address City ZIP Code 3725 N Tracy Blvd Tracy 95376 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Service Station Systems (408 ) 971 -2445 Mailing Address 680 Quinn Ave. San Jose , Ca 95112 Name of UST Service Technician Performing the Certification (Print as shown on the JCC Certification) Kristopher Bell Contractor ! Tank Tester License # ICC Certification # ICC Certification Expiration Date 485184 8833000 7/22/2020 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder Root 4/ 12/2019 VWM61 10/31 /2020 Ill. RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA ® Monitoring System Set- up Alarm History Report Was any monitoring equipment replaced? 0 (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 ? (if 'NoI " describe why in section IV below.) IV, COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. t1 Zf F 1v 1t3 P E ' 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. , manufacturers' checklists, monitoring system set-up , alarm history report, etc . ) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate . UST Service Technician Signature ` CERS = Califomia Environmental Reporting System, ID = Identification, ICC = International Code Coundl, Y = Yes, N = No, NA = Not Applicable