Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 11 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 /> 10180623 3/26/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> COUNTRYSIDE LIQUOR <br /> Business Site Address City FZIP Code <br /> 14971 N . HWY 88 LODI 195240 <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 Street Galt CA 95632 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Edward Stearns <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14 - 1760 Ex . 9/30/20 888308MT 11 /9/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A31048 6/3/2020 <br /> Incon 1009893708 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 /> ❑X Monitoring System Set-up QX Alarm History Report <br /> Was any monitoring equipment replaced ? 11 <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? <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ^ <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 /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 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 = Califomia Environmental Reporting System, ID = Identification, ICC = Intemational Code Council, Y = Yes, N = No, NA = Not Applicable <br />