COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

RECEIVED Appendix VI JUN 0 2 2014 MONITORING SYSTEM CERTIFICATICNVIRONt►,/IENTAL HEALTH For Use By All Jurisdictions Within the State of California r .1 Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, I 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: y g Bldg.No.: Site Address: 15100 N Thornton Rd City: Lodi Zip: 95242 Facility Contact Person: Manager Contact Phone No.: 20( 9 ) 339-4066 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: Tank ID: L In-Tank Gauging Probe. Model: u In-Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: - Piping Sump/Trench Sensor(s). Model: E Piping Sump/Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _ I- Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: Other s2ecify a ui ment type and model in Section E on Pae 2. E Other(specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: r- In-Tank Gauging Probe. Model: n In-Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: E Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: L Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model E Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: , Tank Overfill/High-Level Sensor. Model: Other(specify equipment t e and model in Section E on Pae 2). Other(specify e ui ment type and model in Section E on Page 2). Dispenser ID: 25M Dispenser ID: les K Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 794380-208 x- Shear Valve(s). Id Shear Valve(s). Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chaints). Dispenser ID: 26M Dispenser ID: 26S K Dispenser Containment Sensor(s). Model: 794380-208 4] Dispenser Containment Sensor(s). Model: 794380 208 K Shear Valve(s). )a Shear Valve(s). Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s. Dispenser ID: 27M Dispenser ID: 27S K: Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 X Shear Valve(s). )f] Shear Valve(s). E 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 - 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 Plot 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): xi System set-up c Alarm history report Technician Name(print): Issac Garcia 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 Testing/Servicing:0 5 / 15/ 2 0 1 4 Monitoring System Certification Page of 12107