COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

U E046 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) This form must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the USTs within 30 days of the date of the monitoring system certification . I . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10207021 01 /08/2020 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Pacific Bell Telephone Co . dba AT&T California Business Site Address City ZIP Code 907 Lincoln Rd . Stockton 95207 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # TAIT Environmental Services , Inc. (714) 560-8222 Mailing Address 11280 Trade Center Dr. , Rancho Cordova , CA 95742 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Craig Feezell Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 588098 18374133 07-03-2021 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder- Root A23508 06m2021 Ili . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA ❑X Monitoring System Set-u X❑ Alarm History Report Was any monitoring equipment replaced ? (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below) Was damage , debris, or liquid found inside any secondary containment systems? (If "Yes, " describe what was found in section IV below) El N El Is all monitoring equipment operational per manufacturer's specifications ? (If "No, " describe why in section IV below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. "R r Er J JAN 2 4 2020 ENVIRONMENTAL HEALTH DEPAPTMENT i V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations , Title 23 , Division 3, Chapter 16 , Section 2638 and all information contained herein is true and accurate. Attached to this certification is information (e. g . , manufacturers' checklists , monitoring system set-up , alarm history report, etc . ) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature 4: * 40 ❑ Check If Action Item (s) Are Present CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable