COMPLIANCE INFO_2012-2015 - Laserfiche WebLink

Home Browse Search

MONT*RING SYSTEM CERTIF*kTION 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 he 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: ARCO Bldg.No.: Site Address: 4855 S.State Route 9 City: Stockton, Ca. Zip: 95215 Facility Contact Person: Gill Contact Phone No.: (209) 481-7445 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 1111912012 B. Inventory of Equipment Tested/Certified RECEIVED Check the appro riate boxes to indicates ecific a ui ment ins cted/se"cad: Tank ID: 87 Tank ID: 89 DEC 12 20 2 Z In-Tank Gauging Probe. Model: 847390-109 Z In-Tank Gauging Probe. Model: 847390-109 Z Annular Space or Vault Sensor. Model: 794390-407 Z Annular Space or Vault Sensor. Model: 7943904 ,µ{LTH Z Piping Sump/Trench Sensor(s). Model: 794380-323 Z Piping Sump/Trench Sensor(s). Model: - Z Fill Sump Sensor(s). Model: 794380-344 Z Fill Sump Sensor(s). Model: 794f8 -. 21 ❑Mechanical Line Leak Detector. Model: Z Mechanical Line Leak Detector. Model: 99LD-2000 Z Electronic Line Leak Detector. Model: RJ 2440065 ❑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: Z In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-407 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: 99LD-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: 3&4 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 E Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9&10; 11&12 Dispenser ID: 13&14; 15&16 Z Dispenser Containment Sensor(s). Model: 794380423 Z Dispenser Containment Senors). Model: 794380-323 Z Shear Valve(s). Z 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 - 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 all that apply): 0 syste set-up Z Alarm h'r ry report Technician Name(print): Guadalupe Sanchez Sign e� Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd, Oakdale,Ca.95361 Date of Testing/Servicing: 11/19/2012 Page 1 of 4 Rev(2/08)