COMPLIANCE INFO 2009 - 2018 - Laserfiche WebLink

Home Browse Search

-�5�J Appendix VI MONITORING SYSTEM CERTIFICATION JUN 2 s zoos For Use By All Jurisdictions Within the State of California SAN sOAQUIN COUNTY Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califomia Ct &'4fONMENi AL Regulations iEaLTH DEPA;3TyFNT 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 Names FOOD & GAS VALERO Site AddrPCS2185 Facility Contact Person' E FREMONT YUGIRDER Bldg. No.: City: STOCKTON CA Zip: Contact Phone No.: f-209) 547-1700 Make/Model of Monitoring System: VEEDER ROOT TLS -350 B. Inventory of Equipment Tested/Certified Check the aoarooriate boxes to inrlicarn Date of Testing/Servicing: 6/15/2009 - - -- -- - -- •.y.•• aF.c��cwacrvrceu: ' Tank ID: 870CT Tank ID: DSL 21 In -Tank Gauging Probe. Model: MAG 1 ®In -Tank Gauging Probe. Model: MAG 1 j ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: SPLIT ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ® Fill Sump Sensor(sy Model: 208 ® Fill Sump Sensor(sy Model: 208 i ® Mechanical Line Leak Detector. Model: LD -2000 ® Mechanical Line Leak Detector. Model: STP -MLD -D ❑ 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), Tank ID: 91 OCT Tank ID: ID In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: i❑ Annular Space or Vault Sensor. Model: SPLIT � ❑ Annular Space or Vault Sensor. Model: i® Piping Sump / Trench Sensor(s) Model: 208 ❑ Piping Sump / Trench Sensor(s). Model ® Fill Sump Sensor(s). Model: ii 208 ❑Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP -MLD ❑ 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 n ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floa(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 208 ® Shear Valve(s). ®Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 113- Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ,.......:_ ❑ Dispenser Containment Float(s) and Chain(s). j r contains „wee idnRs 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 generatingsuc reports, I have also attached a copy of the report; (check a// that apply): ® System set-up ® Alarm history report Technician Name (print): David A. Winkler _ Signature: _ Certification No.: 34975 License No: OTT 08-1739 Testing Company Name. AFFORDA-TEST Phone No. (209) 744-0113 -- Testing Company Address: 416 2 STREET GALT, CA 95632 Date of Testing/Servicing: 6-15-09 Monitoring System Certification Page 1 of 4 2/21/07