COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK MONITORINGSYSTEM CERTIFICATION FORM (Page 1 of 6) This form must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A cop) 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 . It FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10186665 3/13/2020 Business Name (Same as Facility Name or DBA- Doing Business As . ) Building # CHEVRON 307709 Business Site Address City: Zip : 10858 TRINITY PKWY STOCKTON 95219 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # TANKNOLOGY INC . (800) 800-4633 Ext, Mailing Address 11000 N . Mopac Expressway #500 , Austin , TX 78759 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification .) Jesus Saldivar Contractor/TankTestey License # ICC Certification # ICC Certification Expiration Date Class A General Engineering 743160 None 6/13/2021 Monitraining and Certifications List all applicable certifications . Expiration Date Tanknology Certification Level III ATG Operability Training Certification Exam 115235 12/31 /2022 ICC CA UST Service Technician None 06/13/2021 Veeder Root VR Level 4 B45334 04/28/2021 VMI TLDT-5000 Tester 3802 11 /12/2021 III. RESULTS OF TESTING/SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA W.' Monitoring System Set-up Alarm History Report Was any monitoring equipment replaced ? r r r (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? r r r (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? r r (If " No, " describe why in section IV below. ) FYI IV. COMMENTS If directed to use this section, describe how and 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 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 CERS=California Environmental Reporting System, ID=Identification, UST= Underground storage tank, ICC=International Code Council