INSTALL_2014 B100 - Laserfiche WebLink

Home Browse Search

Appendix VI 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 control panel by the technician who performs the work. A copy of this farm 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 NamePj101 Flying #618 Bldg.No.: Site Address: 1501 N. Jack Tone Road City: Ripon CA, Zip: 95366 Facility Contact Person: Manager Contact Phone No.:(� Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing:3 /29/ 2 0 1 4 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: t Bio Diesel 20,000 Gallons. Tank ID: TLM Sump x- In-Tank Gauging Probe. Model: 846391-109 U In-Tank Gauging Probe. Model: K: Annular Space or Vault Sensor. Model: 794380303 91 Annular Space or Vault Sensor. Model: 79438(t-so4 Hydro k.-: Piping Sump/Trench Sensor(s). Model: 794380-208 a 304 Hydro ru Piping Sump/Trench Sensor(s). Model: 794380-20e x- Fill Sump Sensor(s). Model: 794380-208 a 304 Hydm 7 Fill Sump Sensor(s). Model: - Mechanical Line Leak Detector. Model: NIA 7 Mechanical Line Leak Detector. Model: - Electronic Line Leak Detector. Model: NIA 7 Electronic Line Leak Detector. Madel: ,e- Tank Overfill/High-Level Sensor. Model: OPW 7180. fl Tank Overfill/High-Level Sensor. Madel: - Other(specify equipment a and model in Section E on Pae 2). ❑ Other�specify equipment t e and model in Section E on Pae 2). Tank ID: Nodh Transition sump Tank ID' South Transition sump In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: x_ Annular Space or Vault Sensor. Model: 794380-304 Hydro x.,. Annular Space or Vault Sensor. Model: 794380304 Hydro { Piping Sump/Trench Sensor(s). Model: 704380-208 K- Piping Sump/Trench Sensor(s). Model: 794380-208 E Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: G Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: U Electronic Line Leak Detector. Model: L Tank Overfill/High-Level Sensor. Madel: Ell Tank Overfill/High-Level Sensor. Model: Other ispecify equipment t e and model in Section E on Pae 2). U Other�sBecify equipment t e and model in Section E on Pa e 2. DispenserlD: Dispenser ID: 1- Dispenser Containment Sensor(s). Model U Dispenser Containment Sensor(s). Model: I: Shear Valve(s), U Shear Valve(s). Dispenser Containment Floats and Chains. 17 Dispenser Containment Floats and Chains. DispenserlD: Dispenser 10: L Dispenser Containment Sensor(s). Model: U Dispenser Containment Sensor(s). Model: L Shear Valve(s). U Shear Valve(s). - Dispenser Containment Floats and Chain(s). U Dispenser Containment Floats and Chain(s). DispenserlD: Dispenser ID: - Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats and Chains 7 Dispenser Containment Floats and Chart(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 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): 9 System set-up to Alarm history report Technician Name(print): Edwin Coreas Signature: ' 2� Certification No.: 834020 License.No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 8( 88 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 3 / 29 / 2 0 1 4 Monitoring System Certification Page of 12/07 APR 16 W4 ENVIRONMENTAL HEALTH DEPARTMENT