COMPLIANCE INFO_1997-2007 - Laserfiche WebLink

Home Browse Search

MONIT&NG SYSTEM CERTIWATION 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 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 Pacili Name: RAPID SERVICE CENTER-CARDLOCK#1004 Bld . No.: Site Address: 3550 HWY 99 Cl : STOCKTON I zip: 952 Facility Contact Person: MIKE ELIASON Contact Phone No.: (209) 948.9412 Make/Model of Monitoring System: INCON Date of Testing/Servicing: JUNE 20, 2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: RED DIESEL Tank ID: REGULAR ® In-Tank Gauging Probe, Model:MAG ®In-Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model:001 ®Annular Space or Vault Sensor. Model: 001 ®Piping Sump/Trench Sensor(s). Model: 001 ®Piping Sump/Trench Sensor(s). Model: 001 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model:_ ® Mechanical Line Leak Detector. Model:FX-IV ®Mechanical Line Leak Detector. Model: STP-MLD ❑Electronic Line Leak Detector. Model:_ ❑Electronic Line Leak Detector. Model:_ ®Tank Ove ll/High-Level Sensor. Model:FLOAT ®Tank Overfill/High-Level Sensor. Model:FLOAT ❑ Other s eci a ui ment a and model in Section E on Pae 2 . ❑ Other(s eci a ui ment a and model in Section E on Pae 2). Tank ID: TanklD:_ ❑ 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 a and model in Section E on Pae 2 . ❑ Other(specify equipment a and model in Section E on Pae 2). Dispenser ID: 11-22 Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model:_ ®Shear Valve(s). ❑Shear Valve(s). ®Dis enser Containment Floats and Chain (s). ❑Dispenser Containment Floats and Chain (s). Dispenser ID: Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Shear Valve(s). ❑Shear Valve(s). F-01Dis enser Containment Floats and Chains . ❑Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID:_ ❑Dispenser Containment Sensor(s). Model:_ ❑Dispenser Containment Sensor(s). Model:_ ElShear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats 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 - 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to the 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 all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): MIKE LAWRENCE Si nature: Certification No:A26642 License: 803105 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testin Servicin : I JUNE 20, 2007 Page 1 of 3 Monitoring System Certification