COMPLIANCE INFO_2018 - Laserfiche WebLink

Home Browse Search

Appendix VI R E MONITORING SYSTEM CERTIFICATION NOV 2 2018 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 Regulations1� r� This form must be used to document testing and servicing of monitoring equipment. A separate certification or �,�}TAL HEALTH each monitoring system control panel by the technician who performs the work. A copy of this form must be p t nkg �s snte9� .nA nA ENT i owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 d8Fol� XA'atAAEN 1 A. General Information Facility Name: Site Address: SAN JOAQUIN REGIONAL TRANSIT Bldg, NO.: 2849 E. MYRTLE STREET city: STOCKTON Facility Contact Person: J O H N Make/Model of Monitoring System: VEEDER ROOT TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Contact Phone No.: R T D zip: 95201 Date of Testing/Servicing: 9/4/2018 `If the facility contains more tanks or dispensers, copy this form. Include information for every i Tank ID: 87 OCT Tank Size: Tank ID: Tank Size: ❑ In -Tank Gauging Probe. Model: N In -Tank Gauging Probe, Model: M A G 7 N Annular Space or Vault Sensor. Model: 3 0 3 ❑ Annular Space or Vault Sensor. Model: N Piping Sump /Trench Sensor(s). Model: 2 0 8 ❑ Piping Sump/ Trench Sensor(s). Model: N Fill Sump Sensor(s). Model: 2 0 8 ❑ Fill Sump Sensor(s). Model: ❑ N Mechanical Line Leak Detector. Electronic Line Leak Detector. Model: Model: PLLD - 8484 ❑ ❑ Mechanical Line Leak Detector. Electronic Line Leak Detector. Model: Model: N Tank Overfill / High -Level Sensor. Model: M A G 7 ❑ 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: DIESEL Tank Size: D T - 2 Tank ID: DIESEL Tank Size: D T - I N In -Tank Gauging Probe. Model: MAG7 N In -Tank Gauging Probe. Model MA G 7 ® Annular Space or Vault Sensor, Model: 3 0 3 N Annular Space or Vault Sensor. Model: 3 0 3 ® Piping Sump / Trench Sensor(s), Model: 2 0 8 N Piping Sump / Trench Sensor(s). Model: 2 0 8 ® Fill Sump Sensor(s), Model: 2 0 8 N Fill Sump Sensor(s), Model: 2 0 8 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: N Electronic Line Leak Detector. Model: PLLD-8484 N Electronic Line Leak Detector. Model: PLLD-8484 i N Tank Overfill / High -Level Sensor, Model: M A G 7 N Tank Overfill / High -Level Sensor, Model: M A G 7 ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: EXTERIOR GAS Dispenser ID: EXTERIOR DIESEL N Dispenser Containment Sensor(s), Model: 2 0 8 N Dispenser Containment Sensor(s), Model: 2 0 8 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: EXTERIOR GAS - BRINE Dispenser ID: EXTERIOR DIESEL - BRINE N Dispenser Containment Sensor(s). Model: 3 0 4 N Dispenser Containment Sensor(s), Model: 3 0 4 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ 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 Float(s) and Chain(s). 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): ®System set-up ®Alarm history report Technician Name (print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2nd STREET GALT, CA 95632 Phone No. (209) 744-0112 Date of Testing/Servicing: 9/4/2018 Monitoring System Certification Page 1 of 4 2/21/07