COMPLIANCE INFO_2016-2018 - Laserfiche WebLink

Home Browse Search

• • RE '� � Appendix VI " ' MONITORING SYSTEM CERTIFICATION MAY 5 2017 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` HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for �IMENTAL�It 7EALTH each monitoring system wntrol panel by the technician who performs the work.A copy of this form must be provided to the tank system t)::FA PTM E'VT, 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: JAMAR SVC Bldg.No.: Site Address: 4076 EAST MAIN STREET City: STOCKTON Zip: Facility Contact JASON Contact Phone No.: (209)462.4685 Person: Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 6/1/2017 B. Inventory of Equipment Tested/Certified Check the atioroDriate boxes to Indicatespecific a ui ment ins ectecilserviced: TanklD: 87 TanklD: 91 ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: SPILT/87 ® 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: PE PETRO ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ID Tank OveRll/High-Level Sensor. Model: FLAPPER ® Tank Overfill/High-Level Sensor. Model: FLAPPER ❑ 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: NA TanklD: NA ❑ 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 Sensogs). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensors). 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 type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). DlspenserlD: 1-2 Dispenser ID: 34 ❑ Dispenser Containment Sensor(.). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Floats)and Chain(.). Dispenser ID: 6-6 Dispenser ID: 7$ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Floats)and Chain(s). Dispenser ID: NA Dispenser 10: NA ❑Dispenser Containment ❑ Dispenser Containment Sensorls). Model: Sensor(.). 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 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 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): FELIX RAMIREZ Signature: — Certification No.: 834976 License No: 5273934-UT 08.1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date or Testing/Servicing: 05-01-17 Monitoring System Certification Page 1 of 4 2/21/07