COMPLIANCE INFO 2007 - 2008 - Laserfiche WebLink

Home Browse Search

Monitoring Systemuipment CertificationFor Use By All Awisdictiont ithin lWe State of California Atatlrority Chad.•Chapter 6.7,Health and Safety Code. Chapter 16, Division 3, Title 23, California Code ofReguladorts This form must be used to document testing and servicing of monitoring equipment. A separate eer ificationer-mport must be for each mortitorbiz§yltem control panel by the technician who perforans 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 foam to the local agency regulating UST system within 30 days of test date. A. General information Facility Name: Rai! s Bldg.No.: Site Address: 4219 Morada Ln. City: Stockton, CA Zip: 95212- Facility Contact Person: Marga Contact Phone No.: (209)9%-9300 Make/Model of Monitoring System: V111 TLS-36W Date of Testing/Se"icing: 7127108 B. Inventory of Equipment Tested/Certified Check trc■pproprtate boxes to iodleste specific equipmeat Inspected/scrviced: Tank W;01#ipu Tank M.,02-Pf m ag in-Tank Gauging Probe. Model: VR"T"MOS IN in-Tank Gauging Probe. Model: VR W390-1 00 Q[ Annular Space or Vauh Sensor, Model: VR Hasa-303 0 Annular Spam nc Vault Sensor. Model= VR 7sa ft-M Qt Piping Sump 1 Trench Sensor(s). Model: VR Tarawa- a Piping Sw T 1 Trench Sensor(s). Model: 'vat 7fata0-w M Fill Swop Sensor(s). Model. VR treses-ma IN Fill Sump Senor(s). Model: yRTsaaaFma C] Mechanical Line Leak fktector. Model: >lone p Mechanical Line Leak Detoctor. Model: M— M Electronic Line Leak Detector. Model: yR era.+ane IN Electronic Line Leak Detector. Model: VR siaaas 9414 0 Tank Overfill 1 High-Level Sens«, Model, N"m p Tank Overfill 1 Higb-Level Sons". Modes; — 13 odd(specify equipnaal type and model in Section E on Page 2). M Other(specify aquiptttatt type and model in Section E on Page 2), Tank Mo I Tank M M In-Tank Gauging Peube. Model vR aasaata (3 In-Tank Gauging Probe. Model: M Annular Space or Vmilt Sensor. Model: VR lar ZW403 Q Annular Spam or Vault Sensor. Model: M Piping Sump 1 Trench Sensor(s). Model: VR TMi a p Piping Swop 1 Trench Sensor(s). Model. ll Fill Sump Sensor(s). Model: vR T9ueama p Fill Sump Sensor(a). Model: Q Mechanical Line Leak Detector. Model: worse C Moctunieal Line Leak Detector. Model: M Ele momio Lina Leask Detccmr. Model: VR 8anss s4sa Cl Electronic Lina Leak Detector. Model- [I Tank Overfill 1 High-Level Sensor, Model: Harr p Tank Overfill 1 High-Level Sensor. Model: G9 Other(specify cquipmew type and model in Section E on Page 2). p ocher(specify equipmciat type and model in Section E on Page 2). Dispenser FD: 01-02 Dispenser ID: 0-W II Digxmw Contaiaanemt Sensor(s). Model: vR 7000-m Dispenser Caataissnont Sensor(a). Mode!' vR 76LUO- a is Shear Valve(s). Q( Shear Valve(s). 0 Dispenser Coniainment Flom(s)and Chain(s). ❑ Mummer Contaimnent Float(s)and Chain(s). 9 Dispenser IDS, Ota 06 I Dispenser 1D: 07.08 IN Dispenser CoRoamad 3enW(s). Modal•_ VR 7wt M-M Q( i)ispea/a Contairmtseat Sensor(a). Mrd; VR 7t+aia616a Q Shear Valve(s), M Shear Valve(s). p 0%peaw Contairancnt Float(s)and Chain(s). 13 Dispmw C.vnta-ent Float(a)and Chain(s). Dispenser ID: 00-10 Dispenser ID0 1142 11 Dispenser Containment Sensor(s). Model: vR 7saa09-M IN Disperser Conhun tent Sensor(a). Model: YR?"Mus 11 Shear Valve(s). I)( Shear Valve(s). t3 D6pema Cmmu went Flm(s)and Chain(s). n Dispenser Containment Fim(s)and Chain(s). 'If the facility eontanu more tanks or dispensers,copy this form.Include information for every fault and dispenser at the facility C.CertifKatiiod- I certify that the equipmemt ldeotifled In this documest was inspected/aerviced in accordsom with the aaooiactar+er's re defists. Attached to this Certilkidoa is Imformatlon(e g.mantdactsm'ebecld o)oeceaaary to verify that this Information Is correct and a Plot Plan showing the layout of monitoring equlpmeaL For any egtslpmeet capable of geseratleg such reports,I have also attached a copy of she, (Chao#sell roar apply): ❑ System set-up L3 Alarm hlatw7 celwrt Technician Nam(print: Stew Patmentsr Signature: s Mfg.Cert.#.: A28780 TCC# 5311561-UT License.Na.: 4$5184 1 Testing Company Name: Sero. Sta.Syts. Phone No., (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose CA 95112 Date of Testing/Servicing: 7122108