Laserfiche WebLink
- `VV <br /> V*o d d F 'N � !Npw <br /> Novi Q011 <br /> UNDERGROUND STORAGE TANK <br /> 43 MONITORING SYSTEM CERTIFNCATlON FORM (Page 1 of s) ' <br /> This form must b j ment testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form <br /> must be prov Ii) I owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br /> I w' Eha date of the monitoring system certification. <br /> - �� t •. 1. FACILI'T'Y INFORMATION <br /> ERS iD Date of Monitoring System Certification <br /> 10181329 4-202020 <br /> -Business Name (Same as Facltily Name or DBA DoingBusiness As.) Building # <br /> MANTECA CHEVRON <br /> Business Site Address City =9'5 <br /> 1257 WEST YOSEMITE =MANTECA <br /> lie . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> FRANZEN HILI (559) 688 — 2977 Ext. <br /> Mailing Address <br /> 1100 N . J STREET TULARE CA. 93274 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br /> DAVID MARTIN <br /> Contractorirank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 304147 5246124 9-16-2Q2Q <br /> Monitoring System Training and Certifications List all applicable certiftoations. Expiration Date <br /> A27289 VEEDER ROOT 2-21 <br /> 1905 VMI 11 -20 <br /> _ - — -- -- -_ 111. RESULTS OF TESTINGISERViCING _ <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> 0 Monitoring System Set-up 0 Alarm History Report <br /> Was any monitoring equipment replaced? <br /> (if "Yost " 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? ® 13 ❑ <br /> (if "Yes, " describe what was found in section IV below,) <br /> is all monitoring equipment operational per manufacturer's specifications? <br /> (If 'Not " 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 /> LIQUID IN THE FILL SUMPS , UDC'S 1 &2 , 5&6 , 7&8 . CLEANED OUT LIQUID <br /> a <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 infonnatia j4e:g.,,7nanu�cturers' gKeckiists, monitoring system set-up, alarm history report, etc . ) necessary <br /> to verifythat this jpfgl natipffand the sit Ian sh vUin the layout of UST system Is complete and accurate. <br /> UST Service Techniclan Signa ure <br /> �,,, ._meq � ._..... . ._ . ..... <br /> It <br /> � .r <br />