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 of this form <br /> 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 <br /> 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 /> 10182103 05/22/ 19 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> United Pacific 5446 <br /> Business Site Address City ZIP Code <br /> 1403 County Club Blvd . Stockton , CA 95204 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> CGRS ( 916 ) 991 - 1100 <br /> Mailing Address <br /> 5444 Dry Creek Road ; Sacramento , CA 95838 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br /> Richard Thomas <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB# 803616 SWR1B#06 - 1672 5254736 11 /03/2020 <br /> Monitoring System Training and Certifications (List all applicable certifications.) Expiration Date <br /> Veeder Root TLS - 3XX Cert . #B34022 11 /02/2020 <br /> Vaporless Manufacturing , Inc . LDT -890 Cert. #2011 08/29/2020 <br /> Ronan Engineering Company Cert . #76090602 09/ 10/2020 <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 History 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 ® ❑ ❑ <br /> below. <br /> Was damage, debris, or liquid found inside any secondary containment systems ? El ® El(If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer' s specifications ? ® ❑ ❑ <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 /> 1 . Power lamp and keypad not 100 % functional upon arrival . Replaced keypad with LED lamps . <br /> r4' <br /> ENVIRONMENTAL HEALTL ' <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 <br /> Richard Thomas <br /> I <br /> CERS = Califomia Environmental Reporting System, ID = Identification, [CC = International Code Council, Y = Yes, N = No, NA = Not applicable <br />