COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

OF11 E C V E D E I Appendix VI JUN 0 2 2014 MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL HEALTH For Use By All Jurisdictions Within the State of California DEPARTMENT 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 farm 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 FI In J 617 Facility Name: y g Bldg.No.: Site Address: 15100 N Thomton Rd City. Lodi Zip: 95242 Facility Contact Person: Manager Contact Phone No.: 20( 9 ) 3394066 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing:0 5 / 15/ 2 0 1 4 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected'serviced: Tank ID: T1 Diesel AST 20,000 Tank ID: T2 Diesel AST 20,000 x- In-Tank Gauging Probe. Model: 848360-109 w In-Tank Gauging Probe. Model: 846364109 Annular Space or Vault Sensor. Model: 846390420 is Annular Space or Vault Sensor. Model: 646390420 )c Piping Sump/Trench Sensor(s). Model: NIA ic Piping Sump/Trench Sensor(s). Model: NIA x- Fill Sump Sensor(s). Model: NIA ;iD Fill Sump Sensor(s). Model: NIA lL Mechanical Line Leak Detector. Model: VMl LD3000 ,c Mechanical Line Leak Detector. Model: VMI LD3000 L Electronic Line Leak Detector. Model: NIA )e Electronic Line Leak Detector. Model: NIA )c Tank Overfill/High-Level Sensor. Model: 846390-109 W/Bazer xD Tank Overfill/High-Level Sensor. Model: 846390109 W/Buzzer L Other(specify equipment t e and model in Section E on Pae 2). ,ei Other(specify equipment t e and model in Section E on Pae 2. Tank ID: T3 Diesel AST 20,000 Tank ID: T5 Bio-Diesel 20,000 In-Tank Gauging Probe. Model: 646390-109 In Tank Gauging Probe. Model: 846390-109 x- Annular Space or Vault Sensor. Model: 846390420 KI Annular Space or Vault Sensor. Model: 846390420 ,t Piping Sump/Trench Sensor(s). Model: NIA C Piping Sump/Trench Sensor(s). Model: NIA Fill Sump Sensor(s). Model: NIA C Fill Sump Sensor(s). Model: NIA L Mechanical Line Leak Detector. Model: NIA d] Mechanical Line Leak Detector. Model: WA Electronic Line Leak Detector. Model: NIA ❑ Electronic Line Leak Detector. Model: NIA x Tank Overfill/High-Level Sensor. Model: 846390-109 w/Buzzer ,d] Tank Overfill/High-Level Sensor. Model: 846390-109 W/Buzzer Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(specify e ui ment t e and model in Section E on Pae 2). Dispenser ID: 19M Dispenser ID: 19S x. Dispenser Containment Sensor(s). Model: 794390-208 X Dispenser Containment Sensor(s). Model: 794360208 x Shear Valve(s). X Shear Valve(s). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chains . Dispenser ID: 20M Dispenser ID: 20S X Dispenser Containment Sensor(s). Model: 794380206 C Dispenser Containment Sensor(s). Model: 794380-208 X Shear Valve(s). 10 Shear Valve(s). Dispenser Containment Floats and Chain(s). D Dispenser Containment Floats and Chains . Dispenser ID: 21M Dispenser ID: 216 ac- Dispenser Containment Senscr(s). Model: 794380-208 KI Dispenser Containment Sensor(s). Model: 794680-208 Pr Shear Valve(s). 41 Shear Valve(s). L Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chains. '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 information(e.g.manufacturers'checklists)necessary to verify that this Information is correct and a Piot 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): L System set-up ❑Alarm history report i Issac Garcia �c—F� Technician Name(print): Signature: Certification No.: 842806 License.No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Test!ng/Servicing:0 5 / 15/ 2 0 1 4 Monitoring System Certification Page of 12107