COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

MONITC, NG SYSTEM CERTIFICA TION Fo a By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3 Title 23, Ch-4nia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system contml panel is installed at the facility,a separate certification or report must be Prepared for each monitoring system control panel by the technician who performs the work. A copy of this toren must be provided to the tank system owner/operator. The owner/operator must submit a copy of this tone to the local agency regulating DST systems within 30 days of test date. A.General Information Facility Name: CIRCLE K 2701205,CO. 123 (N-206) City: LATHROP CA Zip:95330 Site Address: 16470 CAMBRIDGE Contact Phone No: 858-4116 Date of Testing/Service: 05/18/2007 Facility Contact Person: MANAGER Make/Model of Monitoring System:V.R.TLS-350 Work Order Number: 2249172 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1-87 Tank ID: 2-91 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 303 Annular Space or Vault Sensor. Model: 303 X Piping Sumprrrench Sensor(s). Model: 206 Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: RED JACKET(FX1 V) XF.E. Mechanical Line Leak Detector, Model: PETRO(MLD) Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overtill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Others eci ( p fy equipment type and model in Section E on page 2). TanklD: TanklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump7rench Sensor(s). Model: Piping p g Sump/Trench Sensorial. Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverfilliHigh-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). Dispenser : 1/2 Dispenser ID: 3/4 ❑Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). —Xj Shear Valve(s) EX Dispenser Containment Float(s)and Chain(s). X 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($). 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). 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 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 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): JOEY MESA Signature: Certification No.: 006-05-1532 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 05/18/2007 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01