COMPLIANCE INFO 2013 -2016 - Laserfiche WebLink

Home Browse Search

Appendix VI qp RECEIVED MONITORING SYSTEM CERTIFICATION JUN 2 0 2016 For Use By All Jurisdictions Within the State of California F�uk, UA Authority Cited:Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Cod:''0s This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepa&47ERy' L7 each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system '"LJ owner/operator.The ownedoperator 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: SRH Bldg.No.: Site Address: 749 E CHARTER WAY City: STOCKTON CA Zip: 95202 Facility Contact Person: JOHNNY Contact Phone No.: (209)465-8979 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 5.24.2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Fnk87 Tank ID: DSL Gaugng Probe. Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 1 SpaceOrVault Sensor. Model: 407 N Annular Space or Vault Sensor Model: 407 ump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 p Sensor(.). Model: ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: RED JACKET N Mechanical Line Leak Detector. Model: LD 2000 ❑ 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). Tank ID: 91 Tank ID: NA N In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: _ ❑ Fill Sump Sensor(.). Model: ❑ Fill Sump Sensor(.). Model: N Mechanical Line Leak Detector. Model: LD 2000 ❑ 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 ID: 1-2 Dispenser ID: 5-5 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Senators). Model: 208 N Shear valve(s). N Shear Valve(s). ❑ Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(.)and Chain(s). Dispenser lD: 3.4 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(.). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shearvalve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(.)and Chain(s). ❑ Dispenser 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.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 aU that arpty): N System set-up N Alarm history report Technician Name(print): DAVE WINKLER Signature:,--r 1 Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2M STREET GALT CA 95632 Date of Testing/Servicing: 5-24-2016 Monitoring System Certification Page 1 of 4 2/21/07 <�AC