COMPLIANCE INFO 2008 - 2015 - Laserfiche WebLink

Home Browse Search

MONIORING SYSTEM GERTIFIOATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and SafetyCode;Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A scriarate certificatiqnr,re ort must be pj=d for each monitoring system control panel by the technician who performs the work. A copy of this form must be prov 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 NOIVV'12�6 2014 FacilityName: Wine Country76 _-1.1 1 " Site Address: 1111 E. Kettleman Ln. City: Lodi, Ca. PERMIT/9iVMO Facility Contact Person: Sonnie Contact Phone No.: (209) 369-3633 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 10/2212014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: T7: 87 Tank ID: T2: 91 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: 794390.420 E Annular Space or Vault Sensor. Model: PA02591144000 split-tank E Piping Sump/Trench Sensor(s). Model: PA02592000010 E Piping Sump/Trench Sensor(s). Model: PA02592000010 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Seasons). Model: E Mechanical Line Leak Detector. Model: 99LD-2000 E Mechanical Line Leak Detector. Model: FE-Petro STP-MLD ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: E]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). Tank I& T3: Diesel TanklD: ❑ In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: E Annular Space or Vault Sensor. Model: PA02691144000split-tank ❑Annular Space or Vault Sensor. Model: E Piping Sump/Trench Sensor(s), Model: PA02592000010 ❑Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: 99LD-2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/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). F ser ID: 1&2 Dispenser ID: 3&4 penser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ar Valve(s). E Shear Velvets). penser Containment Floats)and Chain(s). E Dispenser Containment Float(s)and Chain(s). ser ID: 5&6 Dispenser ID: 7&8 penser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ar Valve(s). E Shear Valve(s). E Dispenser Containment Floats)and Chain(s). E Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Seasons), Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑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 - t 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 eq ui ment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up ® Alarm history report Technician Name(print): Guadalupe Sanchez Signa�� _ Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.: (209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 10/22/2014 Page 1 of 4 Rev(2/08)