Laserfiche WebLink
20202384 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM(Page I of 6) <br /> This form must be used to document testing and servicing of underground storage tank(USF)monitoring equipment. A copy <br /> 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 <br /> agency regulating the USTs within 30 days of the date of the monitoring system certification. <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181087 8/24/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> Arco 2093 <br /> Business Site Address City ZIP Code <br /> 3425 Trac Blvd Trac 95376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Gettler-Ryan Inc. (925) 551-7555 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G, Dublin, CA 94568 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the/CC Certification) <br /> Elodio Sanchez <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 220793 8887217 8/7/2022 <br /> Monitoring System Training and Certifications List all applicable certifications Expiration Dale <br /> Veeder Root TLS3XXX Tech Cert B41204 7/4/2022 <br /> VMl Line Leak # 3200 12/3/2020 <br /> VMI LDT-890 Leak Detector Tester# 3201 12/3/2020 <br /> Ill. RESULTS OF TESTING if SERVICING <br /> indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> x MonitoringSystem Set-upxQ Alarm Histo Report <br /> Y N NA <br /> Was any monitoring equipment replaced? EJ X(If"Yes,"identiry the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below) <br /> El <br /> Was damage,debris, or liquid found inside any secondary containment systems? Z(if"Yes,"describe what was found in section IV below) <br /> Is all monitoring equipment operational per manufacturers specifications? <br /> (If"No,"describe why in section IV below) <br /> IV. COMMENTS <br /> It directed to use this section,describe how and when the issues were or will be corrected <br /> SEP 1 � 2020 <br /> �NVIRdNM�1�1TA�H <br /> p,�TN <br /> �Fpp� <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br /> Regulations,Title 23,Division 3,Chapter 16,Section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is Information(e.g., ma nufactureryl checklists, monitoring system set-up,alarm history report,etc.) necessary <br /> to verity that this information and tbk site plan stl6fting th la out of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS=California Environmental Reporting System ID=idefVcabon.IGC=Irdemational Code Council Y=Yes.N=No.NA=Not AppGcalole <br />