COMPLIANCE INFO 2007-2012 - Laserfiche WebLink

Home Browse Search

♦ J AfAppendix Vl '�! ❑ MONITORING SYSTEM CERTIFICATION ^t ��El L 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 Coda of � � Regutations �� ++IIVV 9 9 9 equipment, P P p piW O�iUIa)1� i:l+: a I�'EA� H This form must be used to document testing and servicin of monitorin a ui ment.A separate certification or report must be re each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system r_r1lt IT/ CRVIC ES ownerloperator.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 FacNty hKi.. SRH Bldg.No.: Site Arldraafi• 749 E CHARTER WAY City: STOCKTON CA _ Zip: 95202 Facility Contact JOHNY Contact Phone No.: (209)465.8979 percnrc - _- - Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 512 612 01 0 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 87 Tank ID: 89 ® In-Tank Gauging Probe. Model: MAG 1 In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor, Model: 407 ® Annular Space or Vault Sensor. Model: 407 ® Piping Sump I Trench Sensor(s). Model: 208 0 Piping Sump 1 Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Pill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FVIV Z Mechanical Line Leak Detector, ModeL LD 2000 ❑ Electronic Line teak Detector. Model: 0 Electronic Line Leak Detector. Model ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill I 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 El In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor, Model: 407 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 E7 Piping Sump 1 Trench Sensor(s). ModeL ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s) Model: ® Mechanical Line Leak Detector. Model: LD 2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. ModeL © Electronic Line Leak Detector. Model: ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill 1 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: 5-6 E Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model, 208 ❑ Shear Valve(s). ® Shear Valve(s). E] Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 1 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s), Model: 208 ❑ Dispenser Containment Sensor(s), Model: 208 ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)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 Inspectedlservlced 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 Plat 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): 0 system set-up 0 Alarm history report Technician Name(print): DAVE WINKLER Signature: Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744.0113 Testing Company Address: 416 2" STREET GALT,CA 95632 Date of Testing/Servicing: 5-26-10 Monitoring System Certification Page 1 of 4 2/21/07