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 10749253 3/ 13/ 19 Business Name (Same as Facility Name or DBA — Doing Business As.) Building # Costco #038 Stockton Business Site Address City ZIP Code 1630 E . Hammer Ln . Stockton 95210 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Alltech Petro Inc . (209 ) 532 - 7320 Ext . Mailing Address P . O . Box 4208 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) Chad White Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date Ca1323541 /09 - 1747 8152115 2/23/2020 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder- Root ATG Technician #B36877 6/8/2019 Va orless LDT- 890 LDT #2126 5/23/2019 111 . RESULTS OF TESTING/SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA ® Monitoring System Set-up ® Alarm History Report Was any monitoring equipment replaced? El ® El (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? ❑ ® El (if "Yes, " describe what was found in section IV below.) Is all monitoring equipment operational per manufacturer's specifications? ® El El (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. l ffi iS '` t I 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 = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not applicable i