COMPLIANCE INFO 2009 - 2012 - Laserfiche WebLink

Home Browse Search

JOL-02-2010 16:50 Service Station Systerns 408 938 5282 P.03 Monitorin f System Equipment 1rtification For Use Lay All Jurisdictions within The State of California Authoricv Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations 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 system within 30 days of test date. A. General Information Facility Name: Safeway Bldg. No.: Site Address: 1987 West 11Th. Street City: Tracy, CA Zip: 95376 - Facility Contact Person: Manager Contact Phone No.: (209) 830-2950 Make/Model of Monitoring System: V/R TLS -350 Date of Testing/Servicing: 6/2110 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID- 01-Regu-- Tank ID:02-Prem -- GS In -Tank Gauging Probe. Model: VR 3473e0-104 a Irl - Tank Gauging Probe, Model' VR 847390109 Qj Annular Space or Vault Sensor. Modcl: VR 794390370 Ej Annular Space or Vault Scnsor, Model: VR 794190-420 QS Piping Sump \ Trench Sensor (s). Model: VR 794380.208 Qj Piping Sump \ Trench Sensor (s). Modcl: VR 794380-208 Fill Sump Sensor (s). Model: VR 794380-208 13 Fill Sump Sensor (s). Model: VR 794380-208 ❑ Mechanical Linc I,cak Detector. Model. ❑ Mechanical Line Leak Detector. Model: C& Electronic Line Leak Detector, Model: VR $Anes 8484 13 Electronic Linc l .eak Detector. Model; VR series 8484 I] Tank Overfill \ High -Level Sensor, Model' p Tank Overfill \ High•Lcvcl Sensor. Model: p Other ( specify equipment type and model in Section F on Page 2). ❑ Other ( specify equipment type and model in Section C on Page 2). Tank ID-, 03 -Diesel Tank ID' C1 In - Tank Gauging Probe. Model' VR 847390.109 ❑ In - Tank Ciauging Probe. Model: C ,Annular Space or Vault Sensor, Model: VR 794390.420 ❑ Annular Span or Vault Sensor. Model: Cl Piping Sump \ Trench Sensor (s). Model: VR 794380-208 ❑ Piping Sump \ I rench Sensor (s), Model: Q Fill Sump Sensor (s), Model' VR 794380.208 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector, Model: p Mechanical 1..ine Leak Detector. Model; T-1cctronic Line Leak Detector. Model, VR series 8484 p Flectronic Linc Leak Detector. Model: C] Tank Overfill \ High -Level Sensor. Model, ❑ Tank Overfill \ High -Level Sensor, Model' ❑ Other ( speoifv equipment type and model in Section E on Page 2). p other ( specify equipment type and model in Section 8 on Page 2). Dispenser ID. 01-02 Dispenser ID• 03-04 11 Dispenser Containment Scnsor (s). Model: VR 794380.208 12 Dispenscr Containment Sensor (s). Model; VR 794380,208 13 Shear Valve (s). 13 Shear Valve (s). 0 Dispenser Containment Float (s) and Chain (s). p Dispenser Containment Float (s) and Chain (s). Dispenser 10, 05-06 Dispenser iD 07-08 QS Dispenser Containment Sensor (s). Model; VR 794380.208 IX Dispenscr Containment Sensor (s). Model; VR 794380-208 QI Shear Valve (s). IX Shear Valve (s). p Dispenser Containment Float (s) and Chain (s). p Dispenser Containment Float (s) and Chain (s). Dispenser iD- 09-10 _ Dispenser ID: 11.12 IN Disponscr Containment Sensor (s). Model; VR 794380-208 13 Dispenser Containment Sensor (s). Model: VR 794380.208 13 Shear Valve (s), 13 Shear Valve (s). Q 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 - I certify that the equipment identified in this document was inspectedAerwieed in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary to verify that this information is correct and a Plat Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, i have also attached a copy of the; ( check all that apply): 13 Systcm sct-up ❑ Alarm history report Technician Name (print). Bryan Lundien _ Signature: Mfg. Cert.#,; B36094 ICCiI 8001468 -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: 6/2110