Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> This form must be used to document testing and servicing of underground storage tank (UST) 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 /> L FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181191 1 1 / 10/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> TULARE FARMS 1 01 /28/20 Sensor <br /> Business Site Address City ZIP Code <br /> 2771 FRENCH CAMP RD FRENCH CAMP , CA 95336 <br /> li . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> AFFORDA TEST (209 ) 744- 0112 <br /> Mailing Address <br /> 416 2ND STREET GALT , CA 95632 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> EDWARD STEARNS <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 8883080- UT 11 /9/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A31048 6/3/2020 <br /> Incon 1009893708 11 /30/2020 <br /> III . RESULTS OF TESTING I SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> ❑X <br /> Monitoring System Set-up ❑X Alarm History Report <br /> Was any monitoring equipment replaced? El M El <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) <br /> Was damage , debris , or liquid found inside any secondary containment systems? El R El <br /> (if "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? R <br /> (If "No, " describe why in section IV below.) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> 1 / 10/20 COULD NOT REMOVE DIESEL ANNULAR SENSOR SITE WILL CALL MAINT CO <br /> 1 /28/20 Tested EIS annular space sensor in DSL annular after Elite was able to remove <br /> Notification sent to SJC - all complete <br /> Zane Nimmo <br /> 8883064-UT 6- 1 -21 <br /> 04- 1676 Ex . 3/31 /22 <br /> VRVeeder Root A28446 10/2/21 <br /> � ti id 4 j a <br /> a1� gi , a4 . , 1a <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 . , manufacturers' checklists , monitoring system set-up, alarm history report, etc .) necessary <br /> to verify that this information and the site plan showing the layout of UST system is complete and accurate . <br /> UST Service Technician Signature 1 <br /> v1 Js <br /> i <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br /> I <br />