COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Pagel 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 10181511 7/29/19 Business Name (Same as Facility Name or DBA-Doing Business As) Building KwikSery #98 Business Site Address City ZIP Code I 2501 Jackson Ave . Escalon 95320 P P1 I lit UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Service Station Systems (408) 971 -2445 Mailing Address 680 Quinn ave San Jose Ca, 95112 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Brian McPheely Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 485184 8822062 11 /9/2019 Monitorin S stem Trainingand Certifications (List all applicable certifications. ) Expiration Date VR B36745 2/27/2020 VMI 111 /29/2019 Red Jacket 11 / 14/2019 ill . RESULTS OF TESTING 1 SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA Z Monitoring System Set-up ® Alarm Histo 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? El © R (if "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? ® El El (if Woo " describe why in section IV below.) _ IV. COMMENTS If directed to use this section, describe how end when the issues were or will be corrected. V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspectedlserviced 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 CERS = Caffomia Envh)nnwM Reporting System, 10 = Identification, ICC = Intemationd Code Council, Y = Yes, N = No, NA = Not Applicable