COMPLIANCE INFO 2010 - 2018 - Laserfiche WebLink

Home Browse Search

MONITOUNG SYSTEM CERTIFI :TION 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 16140 W.$P � This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must he pre @ 1d or 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. MA'Y' 14 2012 A. General Information ENVIRONMENTAL HEALTH Facility Name: Arco Bldg. NPM1T/SERVICES Site Address: 1100 S. Main St. City: Manteca Zip: 95337 Facility Contact Person: Jessie Contact Phone No.: (209) 609-0117 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/30/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: T1: 87 Tank ID: T2: 91 Z In-Tank Gauging Probe. Model: 847390-109 Z In-Tank Gauging Probe. Model: 847390-109 Z Annular Space or Vault Sensor. Model: 794390-409 Z Annular Space or Vault Sensor. Model: 794390-409 Z Piping Sump/Trench Sensor(s). Model: 794380-323 Z Piping Sump/Trench Sensor(s). Model: 794380-323 Z Fill Sump Sensor(s). Model: 794380-323 Z Fill Sump Sensor(s). Model: 794380-323 Z Mechanical Line Leak Detector. Model: 99LD-2000 Z Mechanical Line Leak Detector. Model: FE STP-MLD ❑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: T3: 89 Tank ID: Z In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: 794390-409 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-323 ElPiping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: FE STP-MLD ❑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: 18x2 Dispenser ID: 384 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 58x6 Dispenser ID: 788 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containfient Sensor(s). Model: 794380-323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9810 Dispenser ID: 11812 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Shear Valve(s). Z 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 - t 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): Z System set-up Z Alarm histo report Technician Name(print): Guadalupe SanchezSignature,•,_ Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.: (209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Seryicing: 3/30/2012 Page 1 of 4 Rev(2/08)