COMPLIANCE INFO_2003 - 2008 - Laserfiche WebLink

Home Browse Search

MONITSING SYSTEM CERTIFI .TION L oc> 7 2lv q 7 For Use By All Jurisdictions Within the State of California � D Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California CodeJ lkeV1gtions O 4 � This form must be used to document testing and servicing of monitoring equipment. A separate certification or re)o; e a��or each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to th 'O erator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. FRV/1 5 Tjtjl t A. General Information Facility Name: Mister Cafe -Valero Bldg.No.: Site Address: 713 N EI Dorado St City: St kton Zip: 95202 Facility Contact Person: �on ct P o e No.: (209) Make/Model of Monitoring System: TLS 35OR to of Testing/Servicing: 4/27/2007 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: /,,M/ Tank ID: T 1 UNLEADED k ID: T PREMIUM ®In-Tank Gauging Probe. Model: 847390-109 ® Tank Gauging Probe. o el: 847390-109 ®Annular Space or Vault Sensor. Model: 794380-302 Ann ar Space or Vault S sdo ode]: 794380-302 ®Piping Sump/Trench Sensor(s). Model: 0794380-208 ®P. mg Sump/Tr tc en r(s). Model: 0794380-208 ®Fill Sump Sensor(s). Model: 0794380-208 ®Fill Sump Sensor(s. Model: V943 0-208 El Mechanical Line Leak Detector. Model: ❑Mechanical m to or. Mode ®Electronic Line Leak Detector. Model: 8484 ®Electronic Lt a Le a ctor. Model: 84 ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Ove - vel Sensor. odel: ❑Other(specify equipment type and model in Section E o P g ❑Other sify e 'pm ent type and tnodelil Section E on Pace 2). Tank ID: T 3 DIESEL Tank 1 ®In-Tank Gauging Probe. Model: 84 90- 09 ❑ - k ging Probe. o e ®Annular Space or Vault Sensor. Model: 0- Space or Vault S ns M del: ®Piping Sump/Trench Sensor(s). Mod 07 3 ❑ n Sump/Trench en r(s). odel: El Fill Sump Sensor(s). Mo el: 943 K. Sump Sensor Model: ❑Mechanical Line Leak Detector. odel: Mechanical Lin L ak D e o Model: ®Electronic Line Leak Detector. 1IV�lq el. Electronic ak et ct Model: ❑Tank Overfill/High-Level Sen or. �M ❑Tank Overfil igh- ev Sensor. Model: ❑Other(specify equipment type an ode/'r Section E on Pag ❑Other, ify pm t type and model in Section E on Page 2). Dispenser ID: 1/2 Disp n er ID: ®Dispenser Containm t ensor( ). Model: 0794380-2 ®D ens r C n inment Sensor(s). Model: 0794380-208 ®Shear Valve(s). V v ). ❑Dispenser Co in en o and Chain(s). ispe ser Containment Float(s)and Chain(s). Dispenser I : /6 Di n er ID: 7/8 ®Dispense Con ' e Sensor(s). Mode. -208 spenser Containment Sensor(s). Modeli 0794380-208 ®Shear Valvv ®Shear Valve(s). ❑Dispenser Containment Float(s) d ain Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 ®Dispenser Containment Sens 0794380- 8 ®Dispenser Containment Sensor(s). Model: 0794380-208 ®Shear Valve(s). O ®Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy is rm. 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): ® System set-up ® Alarm history report Technician Name(print): Gavin Williams Signature: \ Certification No.: 5285969-UT License.No.: 856771 Testing Company Name: HMC - Henderson Maintenance Company Phone No.:(209) 467-7573 Site Address: 713 N EI Dorado St Date of Testing/Servicing: 4/27/2007 Page 1 of 3