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COMPLIANCE INFO_2015 - 2018
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PR0516736
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COMPLIANCE INFO_2015 - 2018
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Entry Properties
Last modified
4/1/2020 11:52:24 AM
Creation date
11/8/2018 10:25:11 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2015 - 2018
RECORD_ID
PR0516736
PE
2361
FACILITY_ID
FA0012764
FACILITY_NAME
SAFEWAY FUEL CENTER #1769
STREET_NUMBER
2802
STREET_NAME
COUNTRY CLUB
STREET_TYPE
BLVD
City
STOCKTON
Zip
95204
CURRENT_STATUS
01
SITE_LOCATION
2802 COUNTRY CLUB BLVD
P_LOCATION
01
P_DISTRICT
003
QC Status
Approved
Supplemental fields
FilePath
\MIGRATIONS3\C\COUNTRY CLUB\2802\PR0516736\COMPLIANCE INFO MARCH 2016 - PRESENT.PDF
QuestysFileName
COMPLIANCE INFO MARCH 2016 - PRESENT
QuestysRecordDate
1/18/2018 5:13:03 PM
QuestysRecordID
3117835
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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Monitoring System Equipment CertificatiO&B 17 2016 <br /> For Use By All Jurisdictions Within The State of California pp��M IVTAL <br /> Authority Cired.•Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Cof_Nv*" <br /> HFA I Tu ncDS RT'A,BCMT <br /> This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be <br /> prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided <br /> to the lank system ownertoperator. The owner/operator must submit a copy of this form to the local agency regulating UST system <br /> within 30 days of test date. <br /> A. General Information <br /> Facility Name:Safeway Bldg.No.: <br /> Site Address: 2808 Country Club Blvd. City: Stockton,CA Zip: 95204- <br /> Facility Contact Person: Manager Contact Phone No.: (209)4615555 <br /> Make/Model of Monitoring System: VR TLS-35OR Date of Testing/Servicing: 1/19116 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced: <br /> Tank IQ,01-Requ Tank IQ-02-Plus <br /> ® In-Tank Gauging Probe. Model: VRU7390-109 00 In-Tank Gauging Probe. Model: VR 847390-109 <br /> 19 Annular Space or Vault Sensor. Model: VR 794390.160 0 Annular Space or Vault Sensor. Model: VR 7947390.160 <br /> R Piping Sump\Trench Sensor(st Model: VR 7943947208 ® Piping Sump\Trench Sensor(s). Model: VR 79a3e0-352 <br /> ® Fill Sump Sensor(s). Model VR 739380.208 ® Fill Sump Sensor(s). Model: VR 790804752 <br /> ❑ Mechanical Line Leak Detector. Model'. ❑ Mechanical Line Leak Detector. Model: <br /> a Electronic Line Leak Detector Model VR SerNe 8494 ® Electronic Line Leak Detector. Model: VR Senn 47184 <br /> 9 Tank Overfill),Higb-Level Sensor. Model: VR TiouniA01 ® Tank Overfill\High-Level Sensor, Model: VR 790091.001 <br /> ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). <br /> Tank IQ: 03-Prem Tank IQ: <br /> 00 In-Tank Gauging Probe. Model: VR 80390-109 ❑ In-Tank Gauging Probe. Model: <br /> ® Annular Space or Vault Sensor. Model: VR 794390-460 ❑ Annular Space or Vault Sensor. Model <br /> ® Piping Sump\Trench Scatter(s), Model. VR 791380-208 ❑ Piping Sump\Trench Sensor(s) Model: <br /> ❑ Fill Sump Sensor(s). Model: VR 794380.362 ❑ Fill Sump Sensor(s). Model: <br /> ❑ Mechanical Line Leak Defector. Model: ❑ Mechanical Line Leak Detector. Model: <br /> ® Electronic Line Leak Detector Model: yR Sen..8484 ❑ Electronic Line Leak Detector. Model: <br /> ® Tank Overfill\High-Level Sensor Model: VR790a91-wl ❑ Tank Overfill\High-Level Sensor. Model' <br /> ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2) <br /> Dispenser ID: 01-02 Dispenser ID: 03'04 <br /> 19 Dispenser Containment Sensor(s). Model: VR 79,1380-322 ® Dispenser Containment Sensor(s) Model: VR 794380-322 <br /> ® Shear Valve(s). ® Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 05-06 Dispenser ID: 07.08 <br /> IM Dispenser Containment Sensor(s), Model: VR 794380.322 ® Dispenser Containment Sensor(s) Model: VR 794380-322 <br /> ® Shear Valve(s) 00 Shcar Vahe(s) <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser ID: 09-10 Dispenser ID: 11-12 <br /> ® Dispenser Containment Sensor(s) Model: VR TUMo322 M Dispenser Containment Sensor(s), Model: "784380-322 <br /> ® Shear Valve(s). M Shear Valve(s). <br /> ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). <br /> 'it the facility contains more tanks or dispensers.copy this form.Include information for every tank and dispenser at the facility <br /> C.Certification - 1 certify that the equipment identified in this document was inspected/cersiced in accordance with the <br /> manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this <br /> information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such <br /> reports,I have also attached a copy of the: (check all that afyd)): ❑ System set-up ❑ Alarm history re/port <br /> Technician Name(print): Kris Bell Signature: 2� <br /> Mfg.Cert.#.: 833709 ICC# 5297793-UT License.No.: 485184 <br /> Testing Company Name: Service Station Systems Phone No.: (408)971-2445 <br /> Testing Company Address: 680 Quinn Ave., San Jose,CA 95112 Date of Testing/Servicing: 1119/16 <br />
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