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COMPLIANCE INFO 1988 - 2006
EnvironmentalHealth
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2300 - Underground Storage Tank Program
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PR0231014
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COMPLIANCE INFO 1988 - 2006
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Last modified
6/5/2019 2:21:43 PM
Creation date
9/20/2018 11:31:35 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO 1988 - 2006
FileName_PostFix
1988 - 2006
RECORD_ID
PR0231014
PE
2361
FACILITY_ID
FA0003777
FACILITY_NAME
TOYS R US
STREET_NUMBER
1624
STREET_NAME
ARMY
STREET_TYPE
CT
City
STOCKTON
Zip
95206
APN
16334002
CURRENT_STATUS
01
SITE_LOCATION
1624 ARMY CT
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
Scanner
KBlackwell
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EHD - Public
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MONIT ' .ING SYSTEM CERTIFICi :ON <br />I-- Jse By All Jurisdictions Within the State of Califomia <br />Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3 Title 23, California Code of Regulations <br />This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, a separate <br />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 <br />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. <br />A. General Information <br />Facility Name: TOYS "R" US <br />Site Address: 1624 ARMY CT <br />Facility Contact Person: MANAGER <br />Make/Model of Monitoring System: VR TLS350C <br />B. Inventory of Equipment Tested/Certified <br />Check the appropriate boxes to indicate specific equipment inspected/serviced <br />City: STOCKTON <br />Contact Phone No: 465-4912 <br />Date of Testing/Service: 09/14/2005 <br />Work Order Number. 2238521 <br />CA Zip: 95297 <br />Tank ID: DSL <br />Tank ID: <br />X In -Tank Gauging Probe. <br />Model: MAG -1 <br />❑ In -Tank Gauging Probe. <br />Model: <br />X Annular Space or Vault Sensor. <br />Model: 420 <br />❑ Annular Space or Vault Sensor. <br />Model: <br />X Piping Sump/Trench Sensor(s). <br />Model: 208 <br />❑ Piping Sump/Trench Sensor(s). <br />Model: <br />Fill Sump Sensor(s). <br />Model: <br />❑ Fill Sump Sensor(s). <br />Model: <br />Mechanical Line Leak Detector. <br />Model: <br />Mechanical Line Leak Detector. <br />Model: <br />Electronic Line Leak Detector. <br />Model: <br />Electronic Line Leak Detector. <br />Model: <br />71 Tank Overfill/High-Level Sensor. <br />Model: ANNUNCIATOR <br />❑ Tank Overfill/High-Level Sensor. <br />Model: <br />Other (specify equipment type and <br />model in Section E on page 2). <br />❑ Other (specify equipment type and model in Section E on page 2). <br />Tank ID: <br />Tank ID: <br />In -Tank Gauging Probe. <br />Model: <br />In -Tank Gauging Probe. <br />Model: <br />Annular Space or Vault Sensor. <br />Model: <br />❑ Annular Space or Vault Sensor. <br />Model: <br />Piping Sumprrrench Sensor(s). <br />Model: <br />❑ Piping Sump/Trench Sensor(s). <br />Model: <br />Fill Sump Sensor(s). <br />Model: <br />❑ Fill Sump Sensor(s). <br />Model: <br />Mechanical Line Leak Detector. <br />Model: <br />❑ Mechanical Line Leak Detector. <br />Model: <br />Electronic Line Leak Detector. <br />Model: <br />Electronic Line Leak Detector. <br />Model: <br />Tank Overfill/High-Level Sensor. <br />Model: <br />Tank Overfill/High-Level Sensor. <br />Model: <br />Other (specify equipment type and <br />model in Section E on page 2). <br />❑ Other (specify equipment type and model in Section E on page 2). <br />ispenser : 1 <br />Dispenser <br />71 Dispenser Containment Sensor(s) <br />Model: 206 <br />Dispenser Containment Sensor(s) <br />Model: <br />X❑ Shear Valve(s). <br />Shear Valves) <br />❑ Dispenser Containment Float(s) and Chain(s). <br />Dispenser Containment Float(s) and Chain(s). <br />Dispenser ID: <br />Dispenser ID: <br />❑ Dispenser Containment Sensor(s) <br />Model: <br />Dispenser Containment Sensor(s). <br />Model: <br />❑ Shear Valve(s). <br />❑ Shear Valve(s). <br />Dispenser Containment Float(s) and Chain(s). <br />Dispenser containment Float(s) and Chain(s). <br />Dispenser lD: <br />Dispenser ID: <br />❑ Dispenser Containment Sensor(s) <br />Model: <br />Dispenser Containment Sensor(s). <br />Model: <br />i <br />❑ Shear Valve(s). <br />❑ Shear Valve(s). <br />10 Dispenser Containment Float(s) and Chain(s). <br />Dispenser Containment Float(s) and Chain(s). <br />If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. <br />C. Certification <br />I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. <br />Attached to this certification is information (e.g manufacturers' checklists) necessary to verify that this information is correct. <br />and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached <br />a copy of the (Check all that apply): ❑ System set-up X❑ Alarm history report <br />Technician Name (print): HEATH MCEVER <br />Certification No.: 006-05-1931 <br />Signature: <br />License. No <br />Testing Company Name: Tanknology Phone No.: (800) 800-4633 <br />Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of Testing/Servicing: 09/14/2005 <br />Page 1 of 3 Based on CA form dated 03/01 <br />Monitorin); System Certification <br />
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