COMPLIANCE INFO 2004 - 2008 - Laserfiche WebLink

Home Browse Search

MAY -19-2005 20:00 Service Station Systems 408 938 8888 P.02 MonitoriA System Equipment Certification For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health and Safery 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 �e 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 2707 Bldg. No.: Site Address: 6425 N. Pacific Ave. 0 Central Ct. City: Stockton, CA Zip: 952047 - Facility Contact Person: Eleanor Contact Phone No.: (209) 472-6600 Make/Model of Monitoring System: WR TLS -350R Date of Testing/Servicing: 4/19/05 B. Inventory of Equipment Tested/Certified .. boxes 10 i-dicate co.rifl. em.inmant it 'it the facility contains Mort tanks m dispensers, copy this form. hiclude 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 (cg. manufactures' checklists ) necessary to verify that this information is wrre0t 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): Q System set-up 0 Alarm history report Technician Name (print): SSS-RaUlS Signature: A -j Q...a d Certification No.: 006-054833 License. No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 6425 N. Pacific Ave. @ Central Ct. Date of Testing/Servicing: 4/19/05 Tank ID Ot•Regu Tank ID Oz -Prem 0 In - Tack Gauging Probe. Model: vR 64739o -t09 0 In - Tank Gauging Probe. Model: VR 61739M1100 W Annular Space or Vault Sensor. Model: 7794390.490 a Annular Space or Vault Sensor. Madel: VR 7943W4W 9 Piping Sump \ Trench Sensor (s). Model: VR 794360309 0 Piping Sump 1 Treach Sensor (s). Model: VR 799390.706 61 Fill Sump Sensor(3). Model: 9R 79x360-206 N Fill Sump Sensor(s). Model: VR 7MM200 O Mechanical tine leak Dotectm Model: None 0 Mechanical Line Leak Detector. Model: None _ Bj Electronic line Irak Detector. Model: yR Transducer oI Electronic Line Leak Detector, Model: VR Tramdueer p Tank Overfill \ High -Level Sensor. Model: None ❑ Tank Overfill \ High -Level Sensor. Model: None ❑ Other ( specify equipment type and model in Section E on Page 2), 0 Other ( specify equipment type and model in Section E on Page 2). Tank ID 03 Diesel Tank In 0 In -Tank Gauging Probe. Model: 7 0 hi - Tank Gauging Probe. Model: vR 94739o-109 W Annular Space or Vault Sensor. Madel: yR 794390460 ❑ Annular Space or Vault Sensor, Model: 7 V Piping Sump\ Trench Sensor(s). Model: yR764990308 ❑ Piping Sump\ Trench Sensor (s). Model: 7 M Pill Sump Sensor (s). Model: VR 70x390-206 p Fill Sump Sensor W. Model: 7 ❑ Mechanical Line Irak Detector. Model: None i] Mechanical Line Leak Detector. Model: 7 ® Electronic line Leak Detector. Model: VR Transducer ❑ Electronic Line Leak Detector. Model: 7 ❑ Tank Overfill \ High -Level Sensor. Model: Nona 0 Tank Overfill \ High -Level Sensor. Model: 7 a Other ( specify equipment type and model in Scotian E on Page 2). 0 Other ( specify cquipmont type and model in Section E on Pager 2)" Dispenser ID• 01.02 Dispenser W! 0303.04 ® Dispenser Containment Sonsca(s). Model: `m7943e0-2o3 0 Disperser Comainmenr Sensor(s). Model: VR 79438a•209 is Shear Valve (s). a Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). 0 Dispenser Containment Float (s) and Chain (s). Dispenser ID• 05 OB Dispenser ED- 07'08 ® Disponser Containment Sensor(s). Model: VR794 209 0 Dispenser Containment Sensor (s). Model: vet 794890•x99 ® Shear Valve (s). R Shear Valve (s). 0 Dispenser Containment Float (s) and Chain (a). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID 08.10 Dispenser ID 11-12 la Dispenser Containment Sensor (s). Model: VR7941300,208 (a Dispenser Containment Sensor(s). Model: V117943404411 ft Shea V01va(8), oI Shear Valve (s)- 0 Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). 'it the facility contains Mort tanks m dispensers, copy this form. hiclude 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 (cg. manufactures' checklists ) necessary to verify that this information is wrre0t 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): Q System set-up 0 Alarm history report Technician Name (print): SSS-RaUlS Signature: A -j Q...a d Certification No.: 006-054833 License. No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 6425 N. Pacific Ave. @ Central Ct. Date of Testing/Servicing: 4/19/05