Laserfiche WebLink
UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (Paget 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 />I. FACILITY INFORMATION <br />CERS ID <br />Date of Monitoring System Certification <br />10/29/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Building # <br />ARCO <br />Business Site Address <br />6009 N. EI Dorado Street <br />City <br />Stockton <br />ZIP Code <br />95207 <br />_ <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br />Phone # <br />Nucleus Pump Services <br />(916) 382-4761 <br />Mailing Address <br />601 1st Ave, Suite B, Sacramento, CA 95818 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br />CHRIS BISHOP <br />Contractor I Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />949066 <br />8216429 -UC <br />5/2/2020 <br />Monitorin S stem Trainingand Certifcations List all applicable certifications. Ex iration Date <br />VEEDER ROOT B36744 6/19/2020 <br />III. RESULTS OF TESTING / SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />Y <br />N <br />NA <br />XX Monitoring System Set -u2 ❑X Alarm History Report <br />Was any monitoring equipment replaced? <br />El <br />❑X <br />❑ <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? <br />El <br />Q <br />❑ <br />(if -Yes. " describe what was found in section IV below.) <br />Is all monitoring equipment operational per manufacturer's specifications? <br />Q <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 />PRE FUEL DROP INSPECTION. ELECTRONIC MONITOR CERT ONLY NO FUEL ON SITE AT THIS TIME. <br />NOV 992018 <br />ENVIRONMENTAL HEALT <br />DEPARTMENT <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 � dj <br />CERS = California Environmental Reporting System. ID = Identification. ICC = International Code Council, Y = Yes. N = No NA = Not Applicable <br />