COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

MONIT%or>RING SYSTEM CERTIFIt--'ATION For Use By All Jurisdictions lMithin the State of California Authority Cited..,Chapter 6.7, Health and Safety Code,Chapter 16,Division 3 Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment If more than one monitoring system control panel is installed at the facility,a separate certification or report must be Prepared for each monilorma 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 form to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: CIRCLE K 2701205 City: LATHROP CA Zip:95330 Site Address: 16470 CAMBRIDGE Contact Phone No: 858-4116 @ LOUISE Date of Testmg/Service: 10/14/2011 Facility Contact Person: ROBERT-PERMIT(N-206-1-4) Make/Model of Monitoring System:TLS-350 Work Order Number: 2283696 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: 87 TanklD: 91 X In-Tank Gauging Probe. Model: MAG 1 X In-Tank Gauging Probe. Model: MAG 1 X Annular Space or Vault Sensor. Model: V/R 303 Annular Space or Vault Sensor. Model: V/R 303 )( Piping Sump/Trench Sensor(s). Model: V/R 208V/R 208 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: VMI LD 2000 X Fill Sump Mechanical Linnee Model: SeriVMI LD2000 Leak eak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: )( Tank Overfill/High-Level Sensor. Model: FLAPPER Tank OverfilVHigh-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). TanklD: Tari In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Madel: Piping Sump/Trench Sensor(s). Model: Piping SumprTrench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Senwgs). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverfilVHigh-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other5 ( pedry equipment type and model in Section E on page 2). Dispenser : 1-2 Dispenser ID: 3-4 ❑Dispenser Containment Sensor(s) Model: Dispenser ContainmentSensor(s) Model: FX Shear Valve(s). —Xj Shear Valve(s) M Dispenser Containment Float(s)and Chain(s). —Xj 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensors) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Flcat(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 I certify that the equipment identified in this document was inspected/serviced in accordancewith the manufacturers'guidelines. Attached to this certification is information(e.g manufacturers'checklists)necessary to verify that this information is correct. and a Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): ❑System set-up X❑Alarm history report Technician Name(print): TIMOTHY COULTER Signature: Certification No.: B34132 License. NO.: 743160(Class'A'General Enginedng Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Testing/Servicing: 10/14/2011 Monitoring System Certification Page 1 of 3 Based on CA forth dated 03/08