COMPLIANCE INFO_2015 - 2018 - Laserfiche WebLink

Home Browse Search

Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Pian available G MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California M113 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cali ornia Code of Regulations ENVIRONMENTAL. This form must be used to document testing and servicing of monitoring equipment. A separate certifi(Y+Afai4j)Fm&ux%ftowpared 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 ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information rff Bldg. No.: Facility Name: Valley Pacific Petroleum Services Site Address: 1524 Fresno Ave. City. Stockton Zip: __CA Facility Contact Person: Mike Eliason Contact Phone No.' 800 266-3782 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 3 1 14 I 2014 B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: DSL X In -Tank Gauging Probe. Model: Veeder Root 846390 Tank ID: In -Tank Gauging Probe. Model: Model: X Annular Space or Vault Sensor. Model VR 420 -794390. TVR Annular Space or Vault Sensor. Piping Sump /Trench Sensor(s). Model: X Piping Sump / Trench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Modes: X Mechanical Line Leak Detector. Model: VMI LD 2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model X Tank Overfill / High -Level Sensor. Model: OPW 61 SO Tank Overfill / High -Level Sensor, Model: Other (specify equipment type and model in Section E on Page 2). Others ci e ui ment type and model in Section E on Pa e 2 . Tank ID: In -Tank Gauging Probe. Model: Tank ID: In -Tank Gauging Probe. Model: Annufar Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump / trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model, Electronic Line Leak Detector. Model: Tank Overfill 1 High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other (s ci equipment type and model in Section E on Pa e 2 . Others ci a ui merit t e and model in Section E on Pae 2 . Dispenser ID: 1-2 X Dispenser Containment Sensor(s). Model: Gilbarco Current Loop Dispenser ID: 2-3 Satellite ser Containment Sensor(s). Model: Gilbarco Current Loop X Shear Dispenser Containment Float(s) and Chain(s). X Shear Valve(s) Dis enser Containment Float s and Chains . Dispenser ID: 3-4 X Dispenser Containment Sensor(s), Model: Veeder Root 794380-208 Dispenser ID: 1 Satellfte X Dispenser Containment Sensor(s). Model: Gilbarco Current Loop X Shear Valve(s), X Shear Valve(s). Dis enser Containment Floats and Chains . Dis enser Containment Float s and Chain s . Dispenser ID: Dispenser Containment Sensor(s). Model _ Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valves) Dispenser Containment Floats and Chains Shear Valve(s). Dis enser Containment Floats and Chain(s). p - *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' to verify that this information is correct guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necess the layout of monitoring equipment. For arty equipment capable of g er ing such reports, 1 have also attached a and a Plot Plan showing copy of the report; (check all that apply): System set-up Alarm history report Technician Name (print): Josh Simmons Signature. G ti n No 5242 gq UT _ License. No.: 4 e + +ca o Testing Company Name: I Testing Company Address: Monitoring System Certification Page 1 of 4 Phone No.:( 661 ) 634-9950 Date of Testing/Servicing: 3 / 14 12014 UP711 it 2/21/07