COMPLIANCE INFO_2016 TO PRESENT - Laserfiche WebLink

Home Browse Search

R E k . I an Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hftp://www.swrcb.ca:gov.)'3! 8 2017 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions within the StateofCalifornia ENVI^('l�lNIE{STAL HEALTI Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code 0 7 n'p � 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 Facility Name: 7-ELEVEN#32190,MKT 2368 Site Address: 4943 S. KINGSLEY(FRONTAGE RD)HWY 99 @ ARCH AIRPORT RD Bldg. No.: Facility Contact Person: MGR-LORENA City: STOCKTON Zip: 95206 Contact Phone No.: 209-939-0679 Make/Model of Monitoring System: Veeder Root TI-S-350 B.Inventory of Equipment Tested/Certified Date of Testing/Servicing! 4/11/2017 Check the appropriate boxes to indicatespecific aqui 3ment ins ected serviced: Tank ID: T4-RUL Tank ID: T5-MUL r In-Tank Gauging Probe. Model: MAG r7l In-Tank Gauging Probe. Model: MAG P Annular Space or Vault Sensor. Model: 794380 302 P Annular Space or Vault Sensor. Model: 794380 302 P_ Piping Sump/Trench Sensor(s). Model: 794380-208 r Piping Sump/Trench Sensor(s), Model: 794380-208 S7 Fill Sump Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model 794380 Electronic Line Leak Detector. Model: Veeder Root PLLD- r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD- r Tank Overfill/High-Level Sensor.Model FLAPPERS r Tank Overfill/High-Level Sensor.Model: FLAPPERS Other(specify,a ui ment type and model in Section E on Pa e 2 . Other(specifyequipment a and model in Section E on Pa e 2). Tank ID: T6-PUL Tank ID: In-Tank Gauging Probe. Model: ETMAGI✓ Annular Space or Vault Sensor. Model -302 r In Tank Gauging Probe. Model: P— Piping Sump/Trench Sensor(s). Model: 794380-208r Annular Space or Vault Sensor. Model: r Piping Sump/Trench Sensor(s). Model: IO Fill Sump Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD- r Mechanical Line Leak Detector. Model: tv Tank Overfill/High-Level Sensor.Model: FLAPPERS r Electronic Line Leak Detector. Model: Other(specifyequipment a and model in Section E on Pae 2). r Tank Overfill/High Level Sensor.Madel; Other(specify a ui ment a and model in Section E on Pa e 2 . Dispenser 1/2 Dispenser ID: ID: 314 Iw Dispenser Containment Sensor(s).Model: 794380-206 17 Dispenser Containment Sensors),Model: 794380-208 W Shear Valve(s). W Shear Valve(s). Fr Dispenser Containment Float(s)and Chain(s). �' Dispenser Containment Float(s)and Chain(s).. Dispenser 516 Ip: Dispenser 7/8 ID: (v Dispenser Containment Sensor(s).Model: 794380-208 r Dispenser Containment Sensor(s).Model: 794380-208 W Shear Valve(s). � Shear Valve(s). F Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser 9/10 Dispenser ID. ID: 11/42 F Dispenser Containment Sensor(s).Model: 794380-208 [v Dispenser Containment Sensor(s).Madel: 794380-208 Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). f Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form.Irdude 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):I%5ystem set- up P Alarm history report Technician Name(print): Jesus Saldivar Signature: Certification No.: B45334 License. No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)80011633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 4/11/2017 Monitoring System Certification Page 1 of 3 12/D7