Appendix VI Underground Storage Tank
Monitoring System Certification Form TYPE OF ACTION
☐ Installation
☒ Repair
☐ 12 Month
1. FACILITY INFORMATION CERS ID
Certification Date
Facility Name Facility Address
City
ZIP Code
2. SERVICE TECHNICIAN INFORMATION Company Performing the Certification
Phone
Mailing Address Service Technician Performing Test Contractor/Tank Tester License Number ICC Number
ICC Expiration Date
3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications
Expiration Date
4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST I hereby certify that the monitoring system is operational in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting documentation is attached; and all information contained herein is accurate. Service Technician Signature
Date
Total # of Pages
CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = SingleWalled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, VPH = Vacuum/Pressure/Hydrostatic Page 1 of 6