Laserfiche WebLink
Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION 11 Installation I 1 Repair Q 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10165823 07/28/2021 <br /> Facilit�r Name <br /> 7-ELEVE #17647,MKT 2368(N-744) <br /> FacilitAddress cit ZIP Code <br /> 1048 W.YOSEMITE AVE @ EL PORTEL MAN ECA 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Com an Performing the Certification Phone <br /> Tanknol gy,In . 800-964-1250 <br /> Mailinq Address <br /> 11000 N Mopac Expy#500 Austin,Tx 78759 <br /> Service Technician Performing Test <br /> Tim Elebeck <br /> ContractorlTank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number IGC Expiration Date <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW:EVR Phase 1 01/01/2022 <br /> VMI:TLDT-5000 Tester 05/25/2023 <br /> Veeder Root:VR Level 4 10/28/2021 <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, chapter 98, section 2638; that required supporting <br /> documentation is attached;and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 07/28/2021 6 <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 />