COMPLIANCE INFO_2015 - 2018 - Laserfiche WebLink

Home Browse Search

MONIr ,RING SYSTEM CERTIFII,ATION e c v/ For Use By All Jurisdictions Within the State of California ECO-CALK COW11-CE Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Titl�ECE a 1 sThis form must be used to document testin and servicin of monitorin equipment. A se arate cCl�tiftfst a or each g g g 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 ofkckal.5 L017 A. General Information Facility Name: ARCO ENVIRONMENTAL HEALTH DEPA � Site Address: 550 W.Valpico Road City: Tracy, CA Zip: 95376 Facility Contact Person: Edgar Rizkalli Contact Phone No.: (925) 548-7910 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 10/26/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced. "rank ID: #1 87 20 000 Gal Tank ID: #2 91 12 000 Gal ®In-Tank Gauging Probe. Model: MAG-1 ®In-Tank Gauging Probe. Model: MAGA ®Annular Space or Vault Sensor. Model: 794380-301 ®Annular Space or Vault Sensor. Model: 794380-301 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ®Fill Sump Sensor(s). Model: 794380-208 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: VR Series 8484 ®Electronic Line Leak Detector. Model: VR Series 8484 ®Tank Overfill/High-Level Sensor. Model: VR Overfill Alarm ®Tank Overfill/High-Level Sensor. Model: VR Overfill Alarm ®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: #3 Diesel 10 000 Gal Tank ID: ®In-Tank Gauging Probe. Model: MAGA ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794380-301 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: VR Series 8484 ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: VR Overfill Alarm ❑Tank Overfill/High-Level Sensor. Model: ®Other(specify equipment type and model in Section F on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser 1D: 11-12 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®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 -1 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): ® System set-up ® Alarm history report Technician Name(print): Nik Zagorov Signature: NZ.�rC>V Certification No.: Veeder Root Level 4#A32784 License.No.: 958763 A Testing Company Name: ECO-CHEK Compliance, Inc. Phone No.:(888) 500-CHEK Testing Company Address: P.O. Box 1394, Lafayette, CA 94549 Date of Testing/Servicing: 10/26/2016 Page 1 of 6 Rev(2/08)