COMPLIANCE INFO 2010 - 2014 - Laserfiche WebLink

Home Browse Search

q-1. 7r11 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hfp://www.swrcb,ca. o ) MONITORING SYSTEM CERTIFICATION � � 2013 For Use By All Jurisdictions Within the State of California E4AMMENT NTAL Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Cal ` 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 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 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 rharir tha annrnnrinta hnvae to indirata enariFr anuinmant inenartaei /eamirad City: MANTECA Zip: 95336 Date of Testing/Servicing: 10/22/2013 Tank ID: T4 - RUL Tank ID: jv In -Tank Gauging Probe. Model: Mag r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 303 r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: 208 Piping Sump / Trench Sensor(s). Model: W Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 17 Mechanical Line Leak Detector. Model: Vaporless LD -2000 Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Flapper Tank Overfill / High -Level Sensor. Model: r 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). Tank ID: T5 - PUL Tank ID: r In -Tank Gauging Probe. Model: Mag r In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: 303 r Annular Space or Vault Sensor. Model: W Piping Sump / Trench Sensor(s). Model: 208 r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Vaporless LD -2000 (� Mechanical Line Leak Detector. Model: I- Electronic Line Leak Detector. Model: (� Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: Flapper r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pacle 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: 208 r Dispenser Containment Sensor(s). Model: 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: r Dispenser Containment Sensor(s). Model: 208 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: I— 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). *1t the taaiity contains more tanks or dispensers, copy tnis torm. >nciucie intormation tor every tanK ana aispenser ac me racwty. 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 r Alarm history report Technician Name (print): Garrett Warren Certification No.: B42126 Testing Company Name: Tanknology Signature: License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Page 1 of 3 Date of Testing/Servicing: 10/22/2013 12/07