Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> mmmm <br /> Fforme used to document testing and servicing of underground storage tank (UST) monitoring equipment A copy of this form <br /> to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br /> ays of the date of the monitoring system certification. <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10182151 10/31 / 19 <br /> Business Name (Same as Facility Name or DBA — Doing Business As) Building # <br /> Ramos Oil Company <br /> Business Site AddressCity ZIP Code <br /> 10842 S . Harlan Road French Camp T95231 <br /> III UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> JP Petroleum Service (916) 372 - 5693 Ext. <br /> Mailing Address <br /> 3065 Asante Lane , West Sacramento Ca 95691 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br /> Gabe Garcia <br /> Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 811471 5281582 1 /20 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root 7/20 <br /> VMI 8/20 <br /> 1116 RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> ® Monitoring System Set-up ® Alarm History Report Y N NA <br /> Was any monitoring equipment replaced? 11 ® El <br /> "Yes, " identify the speck 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 /> 9, OIL <br /> NOV <br /> ENVIRONMEN141 N " <br /> D <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 UST system is complete and accurate. <br /> UST Servi ec *cI4!QA0ature <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = Uftnationai Code Council, Y = Yes, N = No, NA = Not applicable <br />