COMPLIANCE INFO 2017 - 2018 - Laserfiche WebLink

Home Browse Search

Appendix VI RECEIVED MONITORING SYSTEM CERTIFICATION A,`* L 0 2011 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 lations LOf HEALTH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report m �p� each monitoring system control panel by the technician who performs the work.A copy of this form must be provided tot=k' (Q-ES 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: WATERLOO SHELL Bldg.No.: Site Address: 4315 E WATERLOO RD City: STOCK ON CA Zip: 95215 Facility Contact Person: RUPI Contact Phone No.: (209)931-3674 Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 4-10-17 B. Inventory of Equipment Tested/Certified Check the,aEEropriate boxes to indicates ecific equipment ins ected/serviced: Tank ID: 87 OCT Tank ID: 91 OCT E In-Tank Gauging Probe. Model: MAG 1 E In-Tank Gauging Probe. Model: MAG 1 E Annular Space or Vault Sensor. Model: 302 E Annular Space or Vault Sensor. Model: 302 E Piping Sump/Trench Sensor(s). Model: 208 304 ® Piping Sump/Trench Sensor(s). Model: 208 304 E Fill Sump Sensor(s). Model: 208 304 ® Fill Sump Sensor(s). Model: 323 304 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: PLLD E Electronic Line Leak Detector. Model: PLLD ❑ Model: ❑ 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: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ 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: 1-2 Dispenser ID: 5-6 E Dispenser Containment Sensor(s). Model: 208 AND 304 E Dispenser Containment Sensor(s). Model: 208 AND 304 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 E Dispenser Containment Sensor(s). Model: 208 AND 304 E Dispenser Containment Sensor(s). Model: 208 AND 304 E Shear Valve(s). E Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: VENT SUMP Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: 208 AND 304 Sensor(s). Model: ❑ Shear Valve(s). ❑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-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): E System set-up E Alarm history report Technician Name(print): DAVE WINKLER Signature: ___1 Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 4-10-17 Monitoring System Certification Page 1 of 2/21/07