Laserfiche WebLink
UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (Page t of 6) <br />This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment` A copy <br />of this form must be provided to the UST owner or operator. i ne owner of opuLaty, �••..�• ���••••• •• -rr ••• <br />-c .�._ ... ..;& in s .stem certiflcatinn. <br />�I, <br />r .nc re ulatln the ua i s wtmm av ua a of n"c aatc O .••� •• �••••�• ••• _ --_... __. _..____._ <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Monitoring System Certification <br />2/10(20 <br />10180637 <br />Building <br />Business Name (Same as Facility Name or DBA -Doing Business As) I <br />GEMCO RIPON TRUCK PLAZA <br />Business Site Address City ZIP Code <br />F-1 PON, CA 195366 <br />1022 S. FRONTAGE RD <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />1 Name of company Performing the Certification Phone # <br />(209) 744-0112 <br />AFFORDA TEST <br />Mailing Address <br />416 2ND STREET GALT, CA 95632 <br />Name of UST Service Technician Performing the Certification (print as shown on the ICC Certification) <br />EDWARD STEARNS <br />ICC Certification Expiration Date <br />Contractor / Tank Tester License # ICC Certification # 11 /9/2020 <br />14-1760 Ex. 9/30/20 8883080 -UT <br />Ex iration Date <br />Monitorin S stem Trainin and Certifications List all a liceble certifications. 6/3/2020 <br />Veeder Root A31048 11 /30/2020 <br />Incon 1009893708 <br />III. RESULTS OF TESTING I SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br />Y <br />N <br />NA <br />Monitorin System Set-up Alarm Histo Report <br />_ a any monitoring equipment replaced? <br />If `Yes.' identify the specific devices replaced and list the manufacturer and model for all replacement parts in section /V below.) <br />El <br />❑ <br />Was damage, debris. or liquid found inside any secondary containment systems? <br />❑ <br />❑ <br />(if -Yes.' describe what was found in section IV below.) <br />Is all monitoring equipment operational per manufacturer's specifications? N ❑ I ❑ <br />(If "No."describe why in section IV below.) <br />N. COMMENTS <br />If directed to use this section, describe how and when the issues were or will be corrected. <br />I <br />I' <br />I <br />V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br />2638 information contained herein is true and accurate. Attached to <br />rRegulations, Title 23, Division 3, Chapter 16, Section and all <br />ification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary <br />that this information and the site plan showing the layout of UST system is complete and accurate. <br />ice Technician Signature <br />CERS = Cdkmia Envirgnmental RepordN System. ID = Identillcefion• ICC = International Code Cound. Y =Yes. N =No. NA = Not Applicable <br />