Laserfiche WebLink
Appendix V1 <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION Ll Installation LJ Repair M 12 Month <br />l 1. FACILITY INFORMATION <br />CERS ID <br />Certification Date <br />10182305 <br />06/02/2022 <br />Facility Name <br />7 -Eleven #41341 <br />Facility Address City <br />ZIP Code. <br />4405 Pacific Ave Stockton <br />95207 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Perforating the Certification <br />Phone <br />Tanknology, Inc. <br />800-964-1250 <br />Mailing Address <br />11000 N Mopac Expy #500 Austin, Tx 78759 <br />Service Technician Performing Test <br />Jesus Saldivar <br />Contractor/Tank Tester License Number <br />Class A General Engineering 743160 <br />ICC Number <br />ICC Expiration Date <br />8361393 <br />06/11/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root:VR Level 4 (645334) <br />04/21/2023 <br />Veeder Root:Red Jacket Mechanical Line Leak Detector (645334) <br />08/28/2022 <br />VMI:TLDT-5000 Tester (3802) <br />11/07/2023 <br />OPW:EVR Phase 1 (104302) <br />11/23/2022 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />1 hereby certify that the monitoring system is operational in accordance with California Code <br />of Regulations, title 23, division 3, chaprer 16, section 2638; that required supporting <br />documentation is attached; and afl information contained herein is accurate. <br />Service Technician Signature <br />Date <br />Total # of Pages <br />06/02/2022 <br />6 <br />CERS = California Environmental Reporting System; GPH = Gallons Per Hour, ID = Identification, <br />ICC = International Cade Council, LLD = Line Leak Detector, NA = Not Applicable, SUV = Single - <br />Walled, UDC = Under -Dispenser Containment. UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />