COMPLIANCE INFO 2009 - 2012 - Laserfiche WebLink

Home Browse Search

MonitoHn System Equipment Pertification For Use By All Jurisdictions Within The State of California 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: 1804 West 11Th. Street @ Corral Hallow City: Tracy, CA Zip: 95376 - Facility Contact Person: Manager Contact Phone No.: (209) 830-2950 Make/Model of Monitoring System: V/R TLS -350 B. Inventory of Equipment TesteWCertified Check the appropriate boxes to indicate specific equipment inspected/serviced- Date of Testing/Servicing. 813109 Tank ID; Tank I% ❑ In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: ❑ 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). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leal: Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ 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 ID• Tank ID: ❑ In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model.- odel:Annular AnnularSpace or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: p Piping Sump \ Trench Sensor (s). Model: ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector- Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2). ❑ Other ( specify equipment type and model in Section E on Page 2). Dispenser ID: 13-14 Dispenser ID: 15-16 ig Dispenser Containment Sensor (s). Model: yiz 7943ao-208 QS Dispenser Containment Sensor (s). Model:VR 794380-208 Q( Shear Valve (s). Qj Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID: 17-18 Dispenser ID: 19-20 JS Dispenser Containment Sensor (s). Model: va 7943e0 -20e Qj Dispenser Containment Sensor (s). Model: VR 7s4380 -2a 133 Shear Valve (s). QS Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Cham (s). Dispenser TO: Dispenser ID: ❑ Dispenser Containment Sensor (s). Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). p Shear Valve (s). 1 ❑ 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 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 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- U License. No.: 485184 Testing Company Name: Serv. Sta. Sys. Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose CA 95112 Date of Testing/Servicing: 813109