COMPLIANCE INFO_2005 - 2008 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited. Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 13, California Code of Regulations This form most be used to document testing and servicing of monitoring equipment. A seoamte certification or report mast be orenared 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. 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 FacilityName: PG&E Bldg.No.: Site Address: 4040 West Ln City: Stockton Zip: 95204 Facility Contact Person: Michelle Le Contact Phone No.: (209) 602-7038 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 11/25/2008 B. Inventory of Equipment Tested/Certiffed Check the nate boxes to indicate s teifie meat 1 ected/servleed: Tank fill: Unleaded TanktD: Diesel N In-Tank Gauging Probe. Model: MOE2700 N lin-Tank Gauging Probe. Model. 578013-730 Z Annular Space or Vault Season. Model: 794390420 N Annular Space or Vault Sensor. Model: 794390420 Z Piping Sump'Trench Seasot(s). Model: 794380-208 Z Piping Sump i Trench Semot(s). Model: 794380.208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Seasons). Model: ❑Mechanical Lire teak Detector. Model: ❑Mechanical Litre Leak Detector. Model N Electronic fine Leak Detector. Model. 848480.001 Z Electronic fine Leak Defector Model: 848480-001 ❑Tank Overfill/High-Level Sersor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑thha(specify equipment type and model in Section E on Page 2). ❑Other( equipment specify eq p type and model in Section E on Page 2). Tank ID: Waste Oil Tank m: ❑In-Tank Gauging Probe. Model. ❑In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor. Model: 794390420 ❑Anular Space or Vault Sensor. Madel: Z Piping Sump/Trench Stations). Model: 794380.208 ❑Pipung Sump;Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Seasot(s). Model: ❑Mechanical lane Leak Detector. Model: ❑Mechanical line Leak Detector. Model: N Electronic fine Irak Detector. Model: 848480-001 ❑Electronic Line Leak Detector. Model: ❑Tank Overfill i High-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 ID: 1/2 Diesel Dispenser ID: 1 Unleaded N Dispenser Containment Senscos), Model: 794380.208 N Itspenser Containment Sensor(s). Model: 794380-208 Z Shear Valve(s). N Shear Valve(s). Z Dispenser Containment Float(s)and Charts) Z Dispenser Containment Floats)and Chain(s). Dispenser ID: 2 Unleaded Dispenser 1D: N Dispenser Containment Sensor(s). Model: 794380.208 ❑Dispense Containment Sensor(s). Model: N Shear Valve(s). ❑Shear Valve(s). N Dispenser Containment Floats)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser tD: Dispenser ID: ❑Dispenser Containment Sensors). Model: ❑Dispeasa Contaimnent Sertums). Model: ❑Sheer Valve(s). ❑Sbrar Valve(s). ❑Dispenser Containment Float(s)and Chain(s)_ ❑Dispenser Conuaimncnt Finials)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 -1 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 Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,1 have also attached a copy of the report;(check all that apply): ®System set-up ®Alarm history report Technician Name(print): Christopher Thornton Signature: Certification No.: A31M License.No.: 220793 Testing Company Name: Gettler-Ryan ine. Phone No.:(925) 5513777 Testing Company Address: 6747 Sierra CL,Ste J, Dublin Ca Date of Testing/Servicing: 11/25/2008 Pap 1 of 3 Rev(Z(o8)