COMPLIANCE INFO 2007 - 2015 - Laserfiche WebLink

Home Browse Search

,"o, RECEIVED AWT 015 Appendix VI ENVIRONMENTAL (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htt J/www.waterboAtlT&ff_- MONITORING SYSTEM CERTIFICATION For Use By All Junsdictions 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 monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownerloperator. The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General information Facility Name: Lodi CA FO Term Intl Bldg.No.:LODICA Site Address: _2500 West Turner Road City: Lodi zip; 95242 Facility Contact Person: Denise Grisko Contact Phone No.: _ . . 916-205-9291 Make/Model of Monitoring System: pnuemicator TMS 2000 Date of Testing/Servicing: 4=2-2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate spedfic equilpxonenj Ins ectediserviced: Tank ID: die el Tank ID: C In-Tank Gauging Probe. Model: NIP 4505-088-25 13 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model LS-610 ❑ Annular Space or Vault Sensor. Model: S., Piping Sump I Trench Sensor(s). Model: LS 600;LS 660 ❑ Piping Sump 1 Trench Sensor(s). Model: 13 Fifa Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Cl Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: . Tank Overfill 1 High-Level Sensor. Model: RA 200 ❑ Tank Overfill I High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Pa 2). ❑ Other(specify equipment type and model in Section E on Pa 2). Tank ID: Tank ID: ❑ to-Tank Gauging Probe, Model ❑ In-Tarda Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model- ❑ Piping Sump 1 Trench Sensor{s). Model: E3 Fill Sump Sonsor(s). Model- ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model ❑ Electronic Line Leak Detector. Model: O Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: O Other(specify equipment a and model in Section E on Pa 2), ❑ Other s ci ui meet type and modal in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s), ❑ Shear Vatve(s). ❑ Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model= ❑ Shear Valve(s), ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain s. Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). O Dise2nser Containment Float(s)and Chains ❑ 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 Ins pectedlservIced 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 Plot Plan showing the layout of monitoring equipment For any equipment capable of+,eneratili g esuch rlreportsl,I have also 7attached a copy of the report;(check all that apply): ❑System set-up • Alarm history reponDigb11y s�ned/ybj SV€UaV.V IY I�1JV31042i Technician Name{print): David Smith Signature: 041OZ201511009118 Certification No.: 8260473 License.No.: 703190 Testing Company Name: Sunwest Engineering Phone No.:( 909 )594-9850 Testing Company Address: 4780 Cheyenne gyral'Chino Ca. 91710 _. Date of Testing/Servicing! 4=2-2015 Monitoring System Certification Page 1 of 4 12107 QA/QC APPROVED 1 2/21107 4/221201512:04 PMMike P.