COMPLIANCE INFO 1998-2006 - Laserfiche WebLink

Home Browse Search

III,TankrKIll 'ONITORING SYSTEM CERTIFICATION Fti,,8e By All Jurisdictions Within the State of Califomia/ 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 monitonim swtem control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The ownenoperalor 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: CHEVRON#98264 City: TRACY CA Zip:95376 Site Address: 3775 TRACY BLVD Contact Phone No:836-9422 @ 1-205 Date of Testing/Service: 02/19/2003 Facility Contact Person: MGR-PAT Make/Model of Monitoring System: VR TLS350 Work Order Number: 2225443 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: TK1 TanklD: TK2 X In-Tank Gauging Probe. Model: MAG PROBE X In-Tank Gauging Probe. Model: MAG PROBE X Annular Space or Vault Sensor. Model: FLOAT Annular Space or Vault Sensor. Model: FLOAT X Piping Sump/Trench Sensor(s). Model: FLOAT Piping Sump/Trench Sensor(s). Model: FLOAT Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: 71 Electronic Line Leak Detector. Model: ELECTRONIC X Electronic Line Leak Detector. Model: ELECTRONIC Tank Overfill/High-Level Sensor. Model: EXTERNAL ALARM X Tank Overfill/High-Level Sensor. Model: EXTERNAL ALARM 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: TK3 TanklD: X In-Tank Gauging Probe. Model: MAG PROBE In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: FLOAT Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: FLOAT Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: -X1 Electronic Line Leak Detector. Model: ELECTRONIC Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: EXTERNAL ALARM 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: 7/8 X❑Dispenser Containment Sensor(s) Model:SINGLE FLOAT X Dispenser Containment Sensor(s) Model: SINGLE FLOAT X❑Shear VaNe(s). X Shear Valve(s) ❑Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3/4 Dispenser ID: 9/10 ❑ Dispenser Containment Sensor(s) Model:SINGLE FLOAT Dispenser Containment Sensor(s). Model:SINGLE FLOAT X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Floats)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 11/12 ❑X Dispenser Containment Sensor(s) Model: SINGLE FLOATX Dispenser Containment Sensor(s). Model:SINGLE FLOAT FX-1ShearValve(s). X 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 report: ❑X Alarm history report X❑ PRINTED NAME-JOHN R.SMYTH SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01