Laserfiche WebLink
Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ® Installation ❑ Repair ❑ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />10182103 12/2/2021 <br />Facility Name <br />United Pacific # 5446 <br />Facility Address City ZIP Code <br />1403 Country Club Blvd. Stockton 95204 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />R M Fuel Systems Inc. <br />Phone <br />(805) 331-1674 <br />Mailing Address <br />28030 Valcour Drive., Canyon Country, CA. 91387 <br />Service Technician Performing Test <br />Ross McLaren <br />Contractor/Tank Tester License Number <br />836874 <br />ICC Number <br />5255738 <br />ICC Expiration Date <br />06/26/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root Level 4 <br />6/19/2022 <br />Vaporless LDT-890 Tester <br />5/19/2022 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that the monitoring system is operational in accordance with California Code <br />of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br />documentation is attached; and all information contained herein is accurate. <br />Service Technician Signature <br />Date <br />12/2/2021 <br />Total # of Pages <br />CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br />ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single - <br />Walled, UDC = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />