COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

RECEIVED Appendix VI A,U;G 0 2 2313 ENVIRONMENTAL MONITORING SYSTEM CERTIFICATION HEALTH DEPARTMENT For 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 PILOT FLYING J #617 Facility Name: _ Bldg.No.: Site Address: 15100 N.THORNTON ROAD _ City: LODI zip: 95242 Facility Contact Person: JOSE JIMENEZ (STORE DIRECTOR) Contact Phone No.: z( 09 ) 339,4066 Make/Model of Monitoring System:VEEDER ROOT TLS 350, Date of Testing/Servicing:0 7/02/ 2 0 1 3 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Ins ed/serviced: Tank ID:_ Tank ID: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Lu Annular Space or Vault Sensor. Madel: 3 Annular Space or Vault Sensor. Model: C Piping Sump/Trench Sensor(s). Model: 7 Piping Sump/Trench Sensor(s). Model: D Fill Sump Sensor(s). Model: 3 Fill Sump Sensor(s). Model: D Mechanical Line Leak Detector. Model: :1, Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: -1 Electronic Line Leak Detector. Model: - Tank Overfill/High-Level Sensor. Model: 7 Tank Overfill/High-Level Sensor. Model: - Other Lspecify equipment type and model in Section E on Pa 2). 7 Other(specify equipment and model in Section E on Pa 2). Tank ID: Tank ID: In-Tank Gauging Probe. Model: 7 In-Tank Gauging Probe. Model: _ Annular Space or Vault Sensor. Model: -_ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 7 Piping Sump/Trench Sensor(s). Model: _ Fill Sump Sensor(s). Model: 7 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: -_ _-_ _ 7 Mechanical Line Leak Detector. Model: _ Electronic Line Leak Detector. Model: D Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: :3 Tank Overfill/High-Level Sensor. Model: _ Other(specify equipment and model in Section E on Pae 2). C Other(specify equipment and model in Section E on Pa e 2)_ Dispenser ID:#25 DIESEL MASTER Dispenser ID: #25 DIESEL SATELLITE K Dispenser Containment Sensor(s). Model: VR 208 _ x± Dispenser Containment Sensor(s). Model: VR-tee k Shear Valve(s). >F, Shear Valve(s). Dispenser Containment Floats and Chain(s). I Dispenser Containment Floats and Chain(s)- Dispenser hains.Dispenser ID: #26 DIESEL MASTER Dispenser ID: 426 DIESEL SATELLITE X Dispenser Containment Sensor(s)- Model: VR-20e x Dispenser Containment Sensor(s). Model: VR-208 r Shear Valve(s). x Shear Valve(s). Dis22nser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). FDIspenser ID: X27 DIESEL MASTER Dispenser ID:#27 DIESEL SATELLITE Dispenser Containment Sensor(s). Model: VR-206 x Dispenser Containment Sensor(s). Model: VR-2oa Shear Valve(s). x Shear Valve(s). Dispenser Containment Floats and Chains 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 - 1 certify that the equipment Identified In this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capa enerating such reports,I have also attached a copy of the report;(check all that apply): k System set-up AAlarm his port Technician Name(print): JOHNNY SOUZA Signature: Certification No.:A30918 License.No.: 8044 1 Testing Company Name: Jones Covey Group,Inc. Phone No.:(888 ) 972-7581 Testing Company Address:9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing:0 7 10 21 2 0 1 3 Monitoring System Certification Page of 12/07