COMPLIANCE INFO 2009 - 2012 - Laserfiche WebLink

Home Browse Search

Monitoring System Equipment Certification 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 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 Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/servicerl- Date of Testing/Servicing: 7/20/10 Tank ID: 01-Regu ID: 02 -Pre - 3 In - Tank Gauging Probe. 3 Model: VR 847390-10e 13 In - Tank Gauging Probe. Model:VR 847390-109 IN Annular Space or Vault Sensor. Model: VR 794390.420 0 Annular Space or Vault Sensor. Model:VR 794390-420 (3 Piping Sump \ Trench Sensor (s). Model: VR 794380.208 13 Piping Sump \ Trench Sensor (s). Model:VR 794380-2oa Q( Fill Sump Sensor (s). Model: VR 739380-208 EX Fill Sump Sensor (s). Model: VR 794M -20e ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 2 Electronic Line Leak Detector. Model: _VR Sertee 8484 IX Electronic Line Leak Detector. Model: VR 3971.88484 ❑ 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: 03 -Diesel Tank ID% ❑ In - Tank Gauging Probe. Model: VR$47390-109 ❑ In - Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: VR 794390-420 ❑ Annular Space or Vault Sensor. Model: IH Piping Sump \ Trench Sensor (s). '.Model: VR 794380-208 ❑ Piping Sump \ Trench Sensor (s). Model: II Fill Sump Sensor (s). Model: VR 7943a0.208 ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector, Model: CK Electronic Line Leak Detector. Model: VR series 8484 ❑ 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: 01-02 Dispenser ID03 04 , Dispenser Containment Sensor (s). Model: VR 794380-208 IN Dispenser Containment Sensor (s). Model:VR 794380.208 Qj Shear Valve (s). Q( Shear Valve (s). p Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID• 05-06 Dispenser 1% 07-06 (3 Dispenser Containment Sensor (s). Model: VR 794380.208 IN Dispenser Containment Sensor (s). Model: VR 794380-208 % Shear Valve (s). Qj Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID, 09-10 Dispenser ID: 11-12 (3 Dispenser Containment Sensor (s). Model: VR 794390-208 pI Dispenser Containment Sensor (s). Model:VR 794380.208 IN Shear Valve (s). M Shear Valve (s). ❑ 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 as that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Alex Barajas Signature: 0, Mfg. Cert.# 835546 ICC# 5275949 -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: 7120/10