COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 1 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 10181351 12/03/2018 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Fast & Easy #103 Business Site Address City ZIP Code 8660 Lower Sacramento Road Stockton 95212 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Confidence UST Services , Inc . ( 800) 339 - 9930 Mailing Address 16250 Meacham Road , Bakersfield , CA 93314 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Austin Sterling Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 804904 8339953 3/27/2019 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder- Root B45438 5/ 15/2019 Ill . RESULTS OF TESTING I SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA OX Monitoring System Set-up QX Alarm History Report Was any monitoring equipment replaced ? ❑ N ❑ (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? ❑ X❑ ❑ (If "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications ? N ❑ ❑ (If 'No. " describe why in section IV below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. Ej re-? DEC ;i 1 2018 ENVIRONME ri H HEALTH DEPART 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, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable UN -107 www. unidocs .org 1 /6 - Rev. 10/01 /18