Laserfiche WebLink
Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION Ll Installation LJ Repair M 12 Month <br /> 1•1 FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 101816 53 01/20/2022 <br /> Facility Name <br /> CHEVRON 201761 <br /> I1 Fa ci I ity <br /> Address City ZIP Code. <br /> 103 S.MAIN ST.PERMIT NUMB.N-3315 MANTECA 95337 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin,Tx 78759 <br /> Service Technician Performing Test <br /> Jarrod Cooke <br /> Contractor/Tank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number ICC Expiration Date <br /> 8155550 03/18/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root:VR TLS-3XX 04/16/2022 <br /> ICC:CA UST Service Technician 03/18/2023 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitoring system is operational in accordance with California Code <br /> of Regulations. title 23, division 3, chap rer 16, section 2 63 8; that required supporting <br /> documentation is attached; and afl information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 01/20/2022 6 <br /> CERS = California Environmental Reporting System; GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Cade Council, LLD = Line Leak Detector, NA = Not Applicable, SUV = Single- <br /> Walled, UDC = Under-Dispenser Containment. UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />