Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> Fagenifeyfreguul'ating <br /> orm mst be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy <br /> orm ust be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> 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 /> 10180875 4/22/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) Building # <br /> GREWAL' S GAS & LIQUOR <br /> Business Site Address city ZIP Code <br /> 4100 E FREMONT ST STOCKTON , CA 95215 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> AFFORDA TEST (209 ) 744-0112 <br /> Mailing Address <br /> 416 2ND ST . GALT , CA 95632 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> EDWARD STEARNS <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14 - 1760 Ex . 9/30/20 8883080 - UT 11 /9/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder Root A31048 6/3/2020 <br /> Incon 1009893708 11 /30/2020 <br /> III . RESULTS OF TESTING I SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> 0 <br /> Monitoring System Set- up ❑X Alarm History Report <br /> Was any monitoring equipment replaced ? ❑ ❑X 11 <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? <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer' s specifications? X El El <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 /> F.=3 <br /> RE C <br /> .r <br /> MAY 0 7 2019 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMEN-f <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 /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable <br />