Laserfiche WebLink
Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ® Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 12/01/2022 <br /> Facility Name <br /> Country Mart Diesel & Gas <br /> Facility Address City ZIP Code <br /> 34243 S.Chrisman Road Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Central Petroleum Maintenance 925-462-4060 <br /> Mailing Address <br /> P.O. Box 211, Pleasanton,CA 94566 <br /> Service Technician Performing Test <br /> Michael Spring <br /> Contractor/Tank Tester License Number <br /> 491948 <br /> ICC Number ICC Expiration Date <br /> 8898723 11114/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root ATG 09/20/2023 <br /> Vaporless LDT-890 01/10/2024 <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, chapter 16, section 2638; that required supporting <br /> documentation is attached; and all information contained herein is accurate. <br /> Service Technician Si ture Date Total # of Pages <br /> 12/0112022 6 <br /> RS = California Environmental Reporting System, GPH = Gallons Per Hour, 1D = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />