COMPLIANCE INFO 2014 - 2015 - Laserfiche WebLink

Home Browse Search

ECEIVE MONITORING SYSTEM CERTIFICATI This form must be used to document testing and servicing of monitoring equipment. - in-w]Wd Fit tlte tesi-l4y-a-A separate certification or report must be pregared for each monitoring system control panel by the technici WW 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. ENVIRONMENTAL HEALTH A. General Information DEPARTMENT Facility Name: Love's Site Address: 1553 Colony Rd Facility Contact Person: NEIL Make/Model of Monitoring System: TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/sen iced Bldg. No.: City: Ripon Zip: 95366 Contact Phone No.: ( 209) 559-0740 Date of Testing/Servicing: 6/16/14 Tank 1D: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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 type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). "Dank ID: hank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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 type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser Ill: DISP 25 Dispenser ID: 27S X Dispenser Containment Sensor(s). Model: 794380-208 X Dispenser Containment Sensor(s). Model: 794380-208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: DISP 26 Dispenser Ill: X Dispenser Containment Sensor(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s). Model ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s)_ Dispenser ID: DISP 27 Dispenser ID: X Dispenser Containment Sensor(s). Model: 794380 208 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ 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 Site -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): ❑ System set-up ❑ Alarm history report Technician Name (print): RON WOOD A32620 Signature: License. No.: 12559 a,b,c Testing Company Name: L.A.PERKS PLUMBING & HEATING INC. PhoneNo.: 775-358-4403 Site Address: SAME AS ABOVE Page 1 of 3 Date of Testing/Servicing: 6/16/14