COMPLIANCE INFO 1988 - 2006 - Laserfiche WebLink

Home Browse Search

MONIT LING SYSTEM CERTIFIOLTION F'or Use by All Jurisdictions within the State of California Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: TOYS R US US STOCKTON DISTRIBUTION I Site ID # Bld . No.: Site Address: 1624 ARMY COURT Ci : STOCKTON Zi : 95206 Facility Contact Person: JERRY KEATING Model: I Contact Phone No.: (209) 465-4912 Make/Model of Monitoring System: VEEDEROOT TLS 300C ❑ Annular Space or Vault Sensor. I Date of Testing/Servicing: 08/26/2004 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: #1 DIESEL Tank ID: ZIn-Tank Gauging Probe. Model: VR -MAGI ❑In -Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: VR -420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: VR -208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: VR -ATG ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on Pae 2). ❑ Other (s eci equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: ❑In -Tank Gauging Probe. Model: ❑In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (s eci!� equipment type and model in Section E on Page 2). ❑ Other (specify equipment tv e and model in Section E on Page 2). Dispenser ID: #1 Dispenser ID: Z Dispenser Containment Sensor(s). Model: VR -208 ❑ Dispenser Containment Sensor(s). Model: Z Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floa s and Chains . I ❑ Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment FloatW and Chain(s). ❑ Dispenser Containment Flogs) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Flogs) and Chain(s). ❑ Dispenser Containment Floats and Chain(s). If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is the information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Z System set-up Z Alarm history report Technician Name (print): BRADLEY S LARSON Certification No: 000-00-3809 Signature: Testing Company Name: SHIRLEY ENVIRONMENTAL TESTING, L.L.0 Address: 9595 LUCAS RANCH Mnnitnrino Cvctrm ('nrtifir0inn STE 100, RANCHO CUCA Page 1 of 3 Phone No: (909) 476-7443 CA 91730 Date of Testiniz 08/26/2004 03101