COMPLIANCE INFO_2012 - 2016 - Laserfiche WebLink

Home Browse Search

MONIS RING SYSTEM CERTIR ,TION For Use By All Jurisdictions R'ithin the State of California Authorio,Cited:-Chapter 6.7, Health and Safety'Code; Chapter 16, .Division 3, Title 23, California Code of Regulations This forret must be used to d*rcumeatAesting and servicing of monitoring equipment, if mor440_411 _+• F +*-�i se azate certification or to op rt must be grepartd_' each +it rim sv contr a el by the kcchttilOitfn_v�ti t7fAtms the work A.copy of this forma must be provided to the tank system owner/operator. The owner/operator must submit a copy of` i o } local agency regulating UST systems within 30 days of test date.-kms AUG 16 2013 A. General Information gy,�jBQNMRNTAL Facility Nanle: Cruisers Site Address: 1137 W. Lathrpp City: Manteca Zip: 95 Facility Contact Person: TYRONE Contact Phone No.: (209) 824-2760 Make/Model of Nionitoring System: TLS-350 Date of Testing/Servicing: 8/15/2013 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/servicedi: Tank iD: 87 Tank ID: 91 ®In-Tank Gauging Probe. Model: VEEDER ROOT ®In-Tank Gauging Probe. Model: VEEDER ROOT I, ®annular Space or Vault Sensor. Model: 420 ! 2_�knnular Space or Vault Sensor. Model: 420 (�Piping Sump/Trench Sensors) Model: 208 _ 0 Piping Sump/Trench Sensor(s). Model: 208 ®Fill Sump Sensor(s)- Model: 206 N Fill Sump Sensor(s), Modal: 208 El Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Lcak Detector. Model: VEEDER ROOT % �i 1 lectronic Line Leak Detector. Model: VVEDER ROOT Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ®Other(specify equipment tl,pe and model in Section E on Page 2). ( Other(specify equipment type and model in Section E on Page 2). Tank ID: DiESEL Tank 1D: ®Ira-Tank Gaugingg Probe. Model: VEEDER ROOT ElIn-TankGauging Probe. Model:El A ®Annular Spare or Vault Sensor. Model: 420 nnuiw space or Vault Sensor. Model: E Piping Sump/Trench Sensor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: M Fill Sump Scmor(s). Model: 208 ❑Fill Sump Sensor(s). Model: ©Mechanical Line teak Detector. Model: ©Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model' VEEDER ROOT _ ❑Electronic Line leak Detactnr. Model ❑Tank overfill/High-Level Sensor. Model: O�Tannker+il/High-Leel Sensor. Model;Other(specify equipment type and model in§ .tion Eon Page 2). ❑ pecify equipment type and model in Section Eon Page 2). Dispenser ID: 1-2 .Dispenser lD. 3-4 ®Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containrnant Sensors}, Model: 208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ©Dispenser Containment Float(s)and Chain(s). Dispenser TD, 5-6 Dispenser ID: 7-8 El Dispenser Containment Sensor(s)- Model: 208 ®Dispenser Containment Scmor(s). Model- 208 ®shear Valvc(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser led: 9-10 Dispenser ID: 11-12 ®Dispenser Containment Sensor(s) Model; 208 Q Dispenser Containment Sensor(s). Model 208 ( Shear Valve(s) 0 Shear Valve(s). Dispenser Containment Floats)and.Chain(s). ❑Dispenser Containment Floats)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. Cer>tlflCation -l 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 verity that this information is correct and a otylan 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 than apple): ®System set-up Alarms h' tory repo � Technician Name.(print): RUBEN GALINDO Signai,J e: Y. Cettification No.:. 838100 1.iccnse.NO-: Testing Co>xlpany Name: LC SERVICES Photate o.: ��444-1730 Testing Company Address: 388' N.VALENTINE FRESNO CA. 93722 of Testing/Servicing: 811512013 UN-036-1/6 www.unido<s.org Rev.01/17/08