COMPLIANCE INFO 1998-2006 - Laserfiche WebLink

Home Browse Search

..=5 MONITORING SYSTEM CERTIFICATION Use By All Judsdictions Within the State of Califor Authority Cited.Chapter 6.7,`1Ps31th and Safety Code;Chapter 16,Division 3 Title 23-, 3Aifomia 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 monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner operator. a owner operator must sus—mit a mpy o t is ortn to t e 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: 09/26Y2001 Facility Contact Person: MGR-PAT Make/Model of Monitoring System: TLS 350 Work Order Number: 2218655 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: 1 TanklD: 2 In-Tank Gauging Probe. Model: 6473 In-Tank Gauging Probe. Model: 8473 Annular Space or Vault Sensor. Model: 409 X Annular Space or Vault Sensor. Model: 409 Piping SumptTrench Sensor(s). Model: 208 X Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(.). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: PLLD Tank Overfill/High-Level Sensor. Model: 8473 X Tank OverfilUHigh-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). an an In-Tank Gauging Probe. Model: 8473 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 4U9 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping SumprTrench Sensor(s). 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: PLLD 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). Other(specify equipment type and model in Section E on page 2). Spenser ® Dispenser Containment Sensor(s) Model:208 T Dispenser Contalm-s nt Sensor(s) Model:208 ®Shear Valve(s). Shear Valve(s) ❑ Dispenser Containment Floats)and Chablis). Dispenser Containment Float(.)and Chain(s). L)ispenserlu 2 DispenserIU- ® Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). Shear VeNe(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). DispenserlD: 3 DispenserlD: 6 ® Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s). Model:208 ® Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)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; ❑ Alarm history report ❑ PRINTED NAME MATT HEMMINGSEN SIGNATURE: G`1>� COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01