COMPLIANCE INFO_2013 - 2018 - Laserfiche WebLink

Home Browse Search

Appendix VI JUL 0 8 2016 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California _NV�ROtivA��iTAi_ H�AL�t Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be 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 systems within 30 days of test date. A. General Information Facility Name: FAST AND EASY Site Address: Facility Contact Person: 1399 YOSEMITE AVE City: MANTECA DEEP Make/Model of Monitoring System: VEEDER ROOT TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment insp Tank ID: 87 ® In -Tank Gauging Probe. Model: MAG ® Annular Space or Vault Sensor. Model: 303 • Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FX1V ❑ Electronic Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2) Bldg. No.: Zip: 95336 Contact Phone No.: (209) 823-3460 Date of Testing/Servicing: 06-08-16 Tank ID: 91 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 303 • Piping Sump! Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2) Tank ID: DIESEL Tank ID: ® In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 303 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FX1V ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). (specify Dispenser ID: 1-2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser Dispenser ID: 7-8 Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: DispenserID: _ ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). C] 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 - I 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, I have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): FELIX RAMIREZ Signature Certification No.: 5273934 -UT License No: 08-1740 Testing Company Name. AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2nd STREET GALT, CA 95632 Date of Testing/Servicing: 06-08-16 Monitoring System Certification Page 1 of 4 2/21/07