COMPLIANCE INFO 2009 - 2012 - Laserfiche WebLink

Home Browse Search

JIJL-02-2010 1651 Service Station Stysterns 408 938 8888 P.04 MonitorinolSystem Equipment -%rtification For Use By All Jurisdictions Within The Slate of Cal f nrnia Authority 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: 6/2/10 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment iuspeeted/serviced: Tank Ill• Tank ID: ❑ in - Tank Gauoing Probe. Model: ❑ In -'rank Gauging Probe. Meidel: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump 1 Trcnch Scnsor W. Model: ❑ Piping Sump \ french Sensor (s). Modcl: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Scnsor (s), Modcl: ❑ Mechanical Linc leak Detector. Model; ❑ Mcchanical tine Leak Detector. Model,. ❑ Flectronic Line Leak Detector, Model: p Electronic trine Leak Detector. Model; ❑ Tank Overfill \ high -Level Scnsor, Nlodcl: ❑ Tank Overfill 1 High -I .cvet Scnsor. Model: ❑ Other ( specify equipment type and model in Section P. on Page 2). ❑ Other ( specify equipment type and model in Section E on Pagc 2)• TankiD- Tanklll• ❑ In • Tank Gaugins Prohe. Modcl; ❑ In - -1 Link Gauging Probe. Model: ❑ ,annular Space or Vault Sensor. Model: ❑ Annular Space ur Vault Sensor. Model_ ❑ Piping Sump \ Trcnch Sensor (s). Model: _ ❑ Piping Sump \ I Tench Sensor (s). Model: ❑ Fill Sump Sensor (s). Moder ❑ Fill Sump Scnsor (s). Mcxlel: ❑ Mcchanical Line Leak Detector, Model: ❑ Mechanical Linc Lcak Dctcctor. Model: ❑ Electronic Linc I.cak Detector. Model: ❑ P.Icatronic Line Leak Detector, Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section Fon Page 2). ❑ Other ( specify equipment type and model in Section E on Pagc 2). Dispenser ID; 13-1A Dispenser ID 15-16 Dispcnscr Containment Sensor (s), Modcl:VR 794380-20e Dispenser Containment Sensor W. Model: VR 7943110-208 QI Shcar valve (s). Shear Valve (s). ❑ Dispcnscr Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (sj. Dispenser ID• 17-18 Dispenser ID: 19-20 Q( Dispenser Containment Sensor (s). Model; va 794380.208 JX Dispenser Containment Sensor (s). Model: VR 784980-209 {� Shear Valve (s). 13 Shear Valve (s) ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: Dispenser ID: Cl Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Scnsor (s). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispcnser 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 — 1 certify that the equipment identified in this document was inspectedhierviced 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 Plot 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): ❑ system set-up ❑ Alarm history report Technician Name (print): Bryan Lundien Signature: Mfg. Cert.#.: B36094 ICC# 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: 6/2/10