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 /> I . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10181487 5122119 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> Shell #68153 <br /> Business Site Address City ZIP Code <br /> 2448 W Kettleman Ln . I Lodi 95242 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION _ <br /> Name of Company Performing the Certification Phone # i <br /> Service Station Systems , Inc. (408) 971 -2445 <br /> Mailing Address <br /> 680 Quinn ave San Jose Ca , 95112 <br /> Name of UST Service Technician Performing the Certlficaiion (Print as shown on the ICC Certification) <br /> Brian McPheely <br /> Contractor / Tank Tesler License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /9/2019 <br /> Monitoring System Training and Certifications List all applicable certifications. ) Expiration Date <br /> VR B36745 2/27/2020 <br /> VMI 11 /2912019 <br /> III . RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Monitoring System Set- up Alarm Histwy Report <br /> Was any monitoring equipment replaced ? <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? F1 Z El <br /> (If "Yes, " describe what was found in section IV below.) _ <br /> Is all monitoring equipment operational per manufacturer' s specifications? <br /> (lf '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 /> Replaced 87 LD2000 Leak Detector - Retested & Passed . <br /> R E r <br /> t arra <br /> JUN 6 3 2019 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was Inspectediserviced 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 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br /> I� <br /> f <br />