INSTALL 2016 TANK TOP UPGRADE - Laserfiche WebLink

Home Browse Search

Appendix VI RECEIVED (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION FEB 0 2 2011 For Use By All Jurisdictions Within the State of California Authorlty Cited; Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Tit1t1MVW fE"fAefH EALTH Regulations DEPARTMENT 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 systems within 30 days of test date. A. General Information Facility Name: 7 -ELEVEN #19976, MKT 2368 Bldg. No.: Site Address: 1399 N. MAIN ST.@ NORTHGATE City: MANTECA Zip: 95336 Facility Contact Person: BEN Contact Phone No.: 209-239-3252 Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified rhark tha annrnnriata hnvae to indirata cnarifir anuinmant incnartad /comirade Date of Testing/Servicing: 12/19/2016 Tank ID: T4:UNLEADED - RUL Tank ID: TS:PREMIUM - PUL rv— In -Tank Gauging Probe. Model: 847390-107 In -Tank Gauging Probe. Model: 847390-107 r Annular Space or Vault Sensor. Model: 794380-302 rV_0 Annular Space or Vault Sensor. Model: 794380-302 r7 Piping Sump / Trench Sensor(s). Model: 794380-208 rv— Piping Sump / Trench Sensor(s). Model: 794380-208 WO Fill Sump Sensor(s). Model: 794380-208 rV_ Fill Sump Sensor(s). Model: 794380-208 r7 Mechanical Line Leak Detector. Model: Vaporless LD -2000 170 Mechanical Line Leak Detector. Model: Vapod ss LD -2000 r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: V Tank Overfill / High -Level Sensor. Model: Flapper Valve r Tank Overfill / High -Level Sensor. Model: Flapper Valve Other(specify equipment a and model in Section E on Pa e 2). r Other(specify equipment a and model in Section E on Pae 2). Tank ID: Tank ID: r In -Tank Gauging Probe. Model: 7 In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: F Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: F Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: (� Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Page 2). Dispenser 1/2 Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 3/4 Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: 794380-208 r Dispenser Containment Sensor(s). Model: P Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: (� Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r 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 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): r System set- up P Alarm history report Technician Name (print): Darren Sciume Certification No.: B35390 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Signature: License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Page 1 of 3 Date of Testing/Servicing: 12/19/2016 12/07 P� 0 23i'i 3S