COMPLIANCE INFO_2008-2012 - Laserfiche WebLink

Home Browse Search

1 MONI6RING SYSTEM CERTIFOATION 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 This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitorine 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: ARCH ARCO AM/PM Bldg.No.: Site Address: 4855 S HIGHWAY 99 City: STOCKTON Zip: 95215 Facility Contact Person: BILL Contact Phone No.: 209-948-2438 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 11/25/08 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 87 Tank ID: 89 X In-Tank Gauging Probe. Model: MAG-1 X In-Tank Gauging Probe. Model: MAG-1 X Annular Space or Vault Sensor. Model: 0794380406 X Annular Space or Vault Sensor. Model: 0794380406 X Piping Sump/Trench Sensor(s). Model: 0794380-232 X Piping Sump/Trench Sensor(s). Model: 0794380.232 X Fill Sump Sensor(s). Model: 0794380-232 X Fill Sump Sensor(s). Model: 0794380.232 ❑Mechanical Line Leak Detector. Model X Mechanical Line Leak Detector. Model: LD2000 X Electronic Line Leak Detector. Model: RJ CPT ❑Electronic Line Leak Detector, Model: X Tank Overfill/High-Level Sensor. Model: 101 X Tank Overfill/High-Level Sensor. Model: 101 ❑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 TD: 91 Tank ID: X In-Tank Gauging Probe. Model: MAG-1 ❑In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 0794380409 ❑Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 0794380-232 ❑Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: 0794380-232 ❑Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: LD2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: 101 ❑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 ID: 18,2 Dispenser ID: 3&4 X Dispenser Containment Sensor(s). Model: VR 232 X Dispenser Containment Sensor(s). Model: VR 232 X Shear Valve(s). X Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 X Dispenser Containment Sensor(s). Model: VR 232 X Dispenser Containment Sensor(s). Model: VR 232 X Shear Valve(s). X Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 911,10 Dispenser ED: 11&12 X Dispenser Containment Sensor(s). Model: VR 232 X Dispenser Containment Sensor(s). Model: VR 232 X Shear Valve(s). X Shear Valve(s). ❑Dispenser Containment Floats)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 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): X System set-up X Alarm histor rep t Technician Name(print): ED STEARNS Signature: Certification No.: A31048 License.No.: 433159 Testing Company Name: B.Z.Service Station Maintenance Phone No.: (916) 371-2380 Site Address: 630 Houston Street West Sacramento, CA 95691 Date of Testing/Servicing: 11/25/08 Page 1 of 3 UN-036—1/4 www.unidoes.org Rev.01/26/06