COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

RECEIVED Appendix VI ,IUN 02 2014 MONITORING SYSTEM CERTIFICATI ftIRONMENTAL. Hip:ALTH For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 29,�'a#W a 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 9 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: C Piping Sump/Trench Sensor(s). Model: _ ❑ Piping Sump/Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: E Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: E Other�seecify equipment t e and model in Section E on Pae 2). C Other(specifX equipment t e and model in Section E on Page 2. Tank ID: Tank ID: r- In-Tank Gauging Probe. Model: n In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: u 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: E Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: E Tank Overfill/High-Level Sensor. Model: n Tank Overfill/High-Level Sensor. Model: E Other(specify equipment t e and model in Section E on Pae 2). Others ecif equipment t e and model in Section E on Pae 2). Dispenser ID: 28M Dispenser ID: 28S 1�_ Dispenser Containment Sensor(s). Model: 794380.208 K, Dispenser Containment Sensor(s). Model: 794380-208 $t Shear Valve(s). C Shear Valve(s). Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chains. Dispenser ID: 29M Dispenser ID: 29S x Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 794380-208 X Shear Valve(s). C Shear Valve(s). Dispenser Containment Float s)and Chain(s). ❑ Dispenser Containment Float(sj and Chain(s). Dispenser ID: 30M Dispenser ID: 30S >E Dispenser Containment Sensor(s). Model: 794380-208 J0 Dispenser Containment Sensor(s). Model: 794380-20e K_ Shear Valve(s). xj 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 - 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 verity 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 91 Alarm history report i Garca Technician Name(print): Issac 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