COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Pagel 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 10181567 3/26/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Building # PLAZA LIQUORS # 1 Business Site Address City TZIP Code 800 S . CHEROKEE LANE LODI 195240 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Afforda Test (209 ) 744 - 0112 Mailing Address 416 2nd Street Galt CA 95632 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Zane Nimmo Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04 - 1676 Ex . 3/31 / 19 8883064 - UT 6/ 1 /2019 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder Root A28446 9/28/2019 Incon 1009843708 11 /30/2020 III . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA X Monitoring System Set- up QX Alarm History Report Was any monitoring equipment replaced ? (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? (If "Yes, " describe what was found in section IV below.) El X El Is all monitoring equipment operational per manufacturer's specifications ? 0 ❑ (If "No, " describe why in section W below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. I 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 = Califomia Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable