COMPLIANCE INFO 1997-2004 - Laserfiche WebLink

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MONITORING SYSTEM EQUIPMENT CERTIFICATION State and local laws regulations require that equipment which monitors tanks and/or piping systems containing hazardous materials be testedlserviced annually or on a schedule specified by the manufacturer,whichever is more frequent. This form, or a service report with equivalent information,must be used to document testing and servicing of monitoring equipment. If more than one monitoring system(e.g. Veeder-boot TLS-350,Ronan X76S,etc.)is installed at the facility, a separate certification or report must be prepared for each monitoring system by the technician who performs the work. Date of Testing/Servicing: 3-24-00 Facility Name: She]] Site Address: 1071 N.Main St. City: Manteca Zip: 95336 Facility Contact Person: Contact Phone No.: (209)823-5365 Make/Model of Monitoring System: Veeder Root/Simplicity Location of Control Panel: Back Room Make/Model of Line Leak Detector(LLD): Feeder Root/PLLD LLD Leak Threshold: 3.0 d.p.h. Complete the following checklist. X Yes No* Monitoring system isoperable per manufacturer's specifications? X Yes No* Audible alarm isoperational? X Yes No* Visual alarm isoperational? X Yes No* Monitoring system is secured from unauthorized tampering? X Yes No* For pressurized piping systems,do the turbines automatically shut down if the monitoring system detects a leak, fails to operate,or is electrically disconnected? if yes,which monitoring devices initiate positive shut down? NIA PLLD/Sump Sensors i X Yes No* For monitoring systems which serve as tank overfill warning devices,does the overfill warning function operate properly? If so,at what percent of tank capacity does the alarm trigger? 90% NIA *In the comments section below,. describe how and when these deficiencies will be corrected. Check the appropriate boxes to indicatespecific equipment ins ected/serviced; Tank ID No.: Regular Tank ID No.: Premium Tank ID No.: Waste Oil Tank ID No.: Annular Space Sensor X Annular Space Sensor Annuiar Space Sensor Annular Space Sensor Piping Sump Sensor X Piping Sump Sensor Piping Surnp Sensor Piping Sump Sensor X In-Tank Gauging Probe X In-Tank Gauging Probe In-Tank Gauging Probe in-Tank Gauging Probe Dispenser Containment Sensor(s) X Dispenser Containment Sensor(s) Dispenser Containment Sensor(s) Dispenser Containment Sensor(s) Mechanical Line Leak Detector Mechanical Line Leak Detector Mechanical Line Leak Detector Mechanical Line Leak Detector X Electronic Line Leak Detector X Electronic Line Leak Detector Electronic Line Leak Detector Electronic Line Leak Detector Fill Sump Sensor Fill Sump Sensor X Fill Sump Sensor Fill Sump Sensor TLM Sump Sensor TLM Sump Sensor TLM Sump Sensor TLM Sump Sensor Are impact valves operational per manufacturer's specifications? X I YES NO Comments: I certify that the equipment identified above was inspected/serviced in accordance with manufacturers' guidelines. Attached to this Certification is information(e.g.manufacturer's checklist,etc.) necessary to verify that the above information is correct and to describe any repairs,replacement,or recalibration of equipment. Name of Qualified Technician(print): John Talbott Signature: Signature on file at SSS Testing Company Name: Service Station Svstems,Inc. Phone No.: (408)971-2445