COMPLIANCE INFO_2016 - 2018 - Laserfiche WebLink

Home Browse Search

[ ksSY V 111...—` Appendix VI MAY 04 2016 (✓� MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California .i^P1Y1fp1 Qom""' Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Code of Re§WYtiarlet��•"—+� This form must be used to document testing and servicing of monitoring equipment A separate certification or report must be prepared for -t - 1Ca.,4111, 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 forth to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Manteca Liquor Food Bldg.No.: Site Address: 890 N MAIN ST City: MANTECA CA Zip: 96336 Facility Contact Person DEET Contact Phone No.: (209)765-2619 4-18-2016 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 87 OCT TanklD: 91 OCT ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FXIX ® Mechanical Line Leak Detector. Model: FE PETRO ❑ 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). Tank ID: DSL Tank ID: ® In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FXIV D ❑ 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). DispenserlD: 1-2 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Floats)and Chain(s). DispenserlD: 3-4 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® Shear Velvets). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). 'If the facility contains more tanks or dispensers,copy this fort. 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' gulifelines.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): ®System set-up ®Alarm history report Technician Name(print): DAVEWINKLER Signature: Nrz-,__ 7 Certification No.: 5263373-UT License No: 013-1738 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2'd STREET GALT CA 95632 Date of Testing/Servicing: 4-18-2016 Monitoring System Certification Page 1 of 4 2/21)07