COMPLIANCE INFO 2010 - 2015 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION 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 controlyanel 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 Facility Name: Sprint Stockton Bldg.No.: Site Address: 3807 Coronado Ave City: Stockton Zip:95204 Facility Contact Person: Doye Contact Phone No.: (217 )663-9440 Make/Model of Monitoring System:Veeder-Root.TLS 300C Date of Testing/Servicing: 11 f 8 12013 E. Inventory of Equipment Tested/Certified Check the appropriate boxes to incl€tate specific equipment inspected/serviced: Tank ID: Diesel AST 5000 Gal Tank ID: ®In-Tank Gauging Probe, Model: Mag 1 ❑ In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390420 El Annular Space or Vault Sensor. Model: OPiping Sump/Trench Sensor(s), Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: LJ 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:Flapper I V-R Ext Alarm ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify cqui ment a and model in Section E on Fa a 2). ❑ Other(specify equipment ty a and model in Section L on Paxe 2 . Tank ID: Diesel UST 10060 Gal Tank ID: ®ln-Tank Gauging Probe. Model: Mag 1 ❑ In-Tank Gauging Probe. Model: _ ❑O Annular Space or Vault Sensor. Model: 794380-302(Brine) ❑ Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model:794380-208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Cl Mechanical Line Leak Detector. Model: _ ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: OTank Overfill/High-Level Sensor. Model:Flapper/V-R Ext Alarm ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment ri e and model in Section E on Page 2). ❑ Other(specify equipment type anci madel in Section E on Page 2)f Sunup ID:AST Trans sump Dispenser ID: ❑ Sump Containment Sensor(s). Model:_794380-208 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s), Cl Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain s). ❑ Dispenser Containment Floats and Chains Dispenser ID: Dispenser ID: - ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s), ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser 1D: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensar(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑ I]is enser Containment Float(s)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. Cer tifiCation -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 enrrect 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;(cheek all that apply): x System - x Alarm history report Technician Name(print):Peter Jauregui III Signature: ` f Certification No.:_B34641 License.No.: 708231 Testing Company Name:_Jauregui&Culver inc. _ Phone No.: (760) 743-0518 Site Address:959 W.mission Ave Escondido CA 92025 Date of Testing/Servicing:_1l_/_20_/20 1 3 Page 1 of 03/01 Monitoring System Certification