COMPLIANCE INFO_2015 - 2018 - Laserfiche WebLink

Home Browse Search

Monitoring System Equipment Certification For Use By All Jurisdictions Within The State of California Authority Cited..Chapter 6.7, Health and Safety Code; Chapter 16,Division 3. 77tle 23, California Cod.°rt7 Rs;�ulurims This form must be used to document testing and servicing of monitoring equipment. A sparate cenificatiowg ree0ort must.hz 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. The owner/operator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name:Safeway Bldg.No.: Site Address: 2608 Country Club Blvd. City: Stockton,CA Zip: 95204- Facility Contact Person: Manager Contact Phone No.: (209)4615555 Make.Model of Monitoring System: VR TLS-350R Date of Testing/Servicing: 1/20/15 B. Inventory of Equipment Tested/Certified Cheek the appropriate noses to Indicate specific equipment inspected/serviced: Tank IW Tank IQ, ❑ In-Tank Gauging Probe. Model. ❑ In-Tank Gauging Probe. Modem. ❑ Annular Space or Vault Sensor, Model'. ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). ModeC ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Defector. Model: ❑ Mechanical Line Leak Detector. Moder ❑ Electronic Line Leak Detector, Model: ❑ Electronic Line Leak Detector. Model. ❑ Tank Overfill\High-Level Sensor. Model'. ❑ Tank Overfill\High-Level Sensor. Modei- ❑ 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 IQ, Tank III, ❑ in-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. ModiL ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor Model. ❑ Piping Sump\Trench Sensor(a) Model. ❑ Piping Sump\Trench Sensor(a) Model'. ❑ Fill Sump Sensor(s). Model'. ❑ Pill Sump Sensor(s)_ Model- ❑ Mechanical Line Leak Detector. Madel: ❑ Mechanical Line Leak Detector. Model ❑ Electronic Lire Leak Detector. Mudel: ❑ Electronic Line Leak Detector. Model'. ❑ Tank Overfill t high-Level Sensor. Model: ❑ 'tank Overfill l Iligh-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment tvpe and model in Section E on Page 2). Dispenser ID: 13-14 Dispenser ID: 16-16 0 Dispenser Containment Sensor(a). Model: VR 7$4360-322 S Dispenser Containment Sensor(s). ModelVR 704300-372 2 Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- Dispenser ID- ❑ Dispenser Containment Sensor(s). 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(a), Dispenser ID- _ Dispenser ID' ❑ Dispenser Curiumnent Sensor(s) 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 firma Include information for every tank and dispenser at the facility C.Certification - 1 recur-v that the equipment Identined in this document was Inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this information o correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,f have also attached a copy of the; (check all Matapply): ❑ System set-up ❑ Adam history report Technician Name(print): Kris Bell Signature: Mfg.Cert.#.: B33709 ICC# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose,CA 95112 Date of Testing/Servicing: 1/20/15