COMPLIANCE INFO 2012 - 2018 - 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 smarate cirtification 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: 6425 N.Pacific Ave. City: Stockton,CA Zip: 95207- Facility Contact Person: Manager Contact Phone No.: (209)472.8600 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 1118/18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID'01-Regu Tank ID- 02-Prem ® In-Tank Gauging Probe. Model: VR 847390.109 S In-Tank Gauging Probe. Model: VR847390-los 11 Annular Space or Vault Sensor. Model: VR 79439o4e0 ® Annular Space or Vault Sensor. Madel: VR 794390460 0 Piping Sump\Trench Sensor(9). Model: VR 794360-209 0 Piping Sump\Trench Sensor(a). Madel: VR 794380-20e ® Fill Sump Sensor(s). Model: VR 794380-209 0 Fill Sump Sensor(s). Model: VR 794380-209 ❑ Mechanical Line Lcak Detector. Model: ❑ Mechanical Line Leak Detector. Model: - R Electronic Line Leak Detector. Model: VR Series 8484 ® Electronic Line Leak Detector. Model: VR eedaa 9484 all Tank Overfill l High-Level Sensor. Model: VR 790091-007 01 Tank Overfill\High-Level Sensor. Model: VR7901191-oat ® Other(specify equipment type and model in Section Eon Page 2). ® Other(specify equipment type and model in Section E on Page 2), Tank ID: 03-Diesel Tank ID: 09 In-Tank Gauging Probe. Model: VR 647390-109 ❑ In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor, Model: VR 749990469 ❑ Annular Space or Vault Sensor. Model: 00 Piping Sump 1 Trench Sensor(s). Made[- VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: ® Fill Sump Sensor(a). Model: VR 794380¢08 ❑ Fill Sump Sensor(a). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 2 Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor. Model: VR 790091wool ❑ 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 ID: 03.04 ® Dispenser Containment Sensor(a). Modcl: VR 79439040/1 ® Dispenser Containment Sensor(a). Model: VR 794360-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05.06 Dispenser iD: 07-08 ® Dispenser Containment Sensor(s). Model: va 794380.208 ® Dispenser Containment Sensor(s). Model: VR794360-206 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). EDispenser,ID: 09-10 Dispenser ID: 11.12ontainment Sensor(s). Model: VR79U6a-209 ® Dispenser Containment Sensor(s). Madel: VR 749390.299 ve(s). ® ShearValve(s). 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 inspeetedrserviced 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; (cheekaR thatapply): ® System set-up 0 Alarm history report Technician Name(print): Kris Bell Signature: Mfg.Cert.#.: B33709 ICC# 5297793-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: 1118/18