COMPLIANCE INFO 1998-2003 - Laserfiche WebLink

Home Browse Search

NIONITORING SYSTEM CERTIFICATION For Use By All JurisdictionsWthfit the State of California. Aafhority Cited:Cltapter6.7.Health and Sgfery Code:Chapter 16, Division 3, Tide 23,Catifornio Code of Regulmiow This form must be used to document testing and servicing of monitoring equipment A separate Certification or report most be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form most be provided to the tank system owner/operator. The owoednnerator must submiLa_comt-oBbis.-form to the)oca)_aag regulating UST systems within 30 days of rest due. TIME OIL 04-167 A. General Information 1434 W. YOSEMITE AVE. Facility Name: MANTECA, CA 95336 _ Bldg.No.: Site Address: Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System:--11-S Date of Testing/Servicing' B. Inventory of Fgtdpment Tested/Certified Check the to boxes to Sadwt: re meat' ted/sxtriccd: TankID: t�CrTankID: Qf Took Ganging Pto6e. WV-del; -)�('7 81_ba-Tank ranging probe Model: 4 -72 P,Annular Space or Vank Sensor. Model: 4; U Anular Space or Vault Setuta. Model It 7..-. M-P*ng Sump/Trench SeuorfSZ Mode: _ ) ,,Piping Sump l peach Swsar(s} Model: Z.17- 0 erO Fill Sump Semcor(s), Mndc: 11 Fin Sump S--(s)_ me"-- 0 Medmnieal line Leak Detector. ModcL (-'.r I @tMechemeal iimIedcDetenor. Model: SrJ2-H/ Q O Eecnonic we Leak Detector. Model: ?Clecnomc Lim Leak Dm=m- Model: Q Tank Overall t High-level Sensor. Modes: ❑Tank G-edM I Mgju-Level Seasor, Model: O Other(Spoiafv equipment type and model to Serum E on Pazc 21. U Other( uipment typeand model in Section E on Pae 2). rftl3l'Irr P TankED- Tank CmgingPmbm Model: 0In-Tank Gauging Probe Model: s❑ Ann,d"Space or Vault Seamy. Mode: Sze ❑Annular Speaeor Vault Savor. Model Piping Sump I Trench Sensor(s). Model: 'P,C ❑Piping Some I Trench Senser(s). Model: Pill Smmt Seaws). Model: ❑Fill Sunap Smsur(.$). Maley El Mechanical lane Leak Demcwr. Model: t'i Y7 V1 t-D aMuhaaica7Iiaelcaklhteaor. Model: O scaroaicline Leak Detector, Model: U L1loc4mcdcl meLmkDetraaor. Model: (]Tank Overfill 1 Hipp-Level Seasm Model: ❑ Tank Overfill i Higta-L awl Sensor- Model Q Odtar t tyne and ma3A in Secum E on page 2). D type and❑odd in Sccmon B on Page 2). Dispenser m: Wspetmer In. .F{DispmserContainauear Seasot(s). Model' AA.-. U Disloacr Coetanmua Seosne(s). Madel- -QJF,r-„ k2 Shea Valve(s). @ Shear Valvr(s) A3 Dispeom Contaummt Hoat(s)and Chain(s). 1-4 Dispenser Containment FIDWs and Chain(s). D)spmser lD: Dfspeaser ID: �: RMspeater C^rtammerr Seasor(s). Model: ('--,r` .r.,.. aDispensm Conteiareat Seasons). Model: vl, �€r.,. . p k�Shea valve(s). �.Sheer valvefst 4 LD' ser Containment Float(s)and s). tH Como nane^t F1oat(s)and Chan(s). Dispenser ID: DID: Disprnser Conumuccutsensnt(s). Modr}: ODispea�Coarainmem Seosa(s). Model '3 Shear Valsa(s)_ O Shear V d%V(s2 1 " ser Contaimreat Roads)and Chains. Lk Dispmp,r Containment Floats)and C(aints). S; 'U the facility contains morn tanks ar dispensers,copy rids form. Made iafornation for every rank and dispenser u the facility. C. Certification-i cerate that the equipment identified in this da®eat was mspected/servked In accordance with the mmutactuners, gu ideunts Attached to tics Certification Is)reformation(eg.meaafncft u 'daccidists)necessary to vet*that this iLtotmation is cor-rect and a Plot Pian show®gthe hgnaa ormonkoting � . Fw atw egoilamat tapable of generating soch reports,I have also aftached a copy of the ce-oerr�C�(ef¢ek apply): set-up R istM m$ert Technician Nano:(print): t s i l Signature Certification NO.: 7 2�'�d Liccos Nw Testing Company Name- .Pym NoJ 707 j (0 15/ Sia:Address: ►`i 3�{ VJ . y Se YY2 w- Au-- im�., e�fz> �sar;; 7iQ3 Page l oF3 - M1 Monitoring System C"ficatiou