COMPLIANCE INFO_2013 - 2018 - Laserfiche WebLink

Home Browse Search

URINE SYSTEM CERTIFICATI MONITORING I VED ECEN f•orl;re FjtHr..Arrr.c</a�tre:ns:f"rlhrrrrheS7tueol'(ialtlprvtiit MMQd�� htdoo-ur Cited.C lagNer&-,.Health uud 1o1c n r"n/ t'hupier,16 tt rimon t, title.23.C'�aliforaw t h'of Bt-k/AX,,r2 3 2013 Thi.,,form musl he ti-AA to dotuntent testing and servicing of monit(tring equipment !xparttte eac naff"I"11 SI)NW n„rvntnal iiiknel by the Welinician who perhoins the waric. A cop)nf'this ft7rttt n nsl be provided to tate tato;syg tel v o�T�lr mils(Submit t uapc isf Fha+Gann it)the local agent}regulating,t I'�l systlms within Ie),#aft of te51 rkttk H A. General Information DEPgRTMENT Fatality Name: MANTECA ARCO _ Coen y: SAN JOAA LittN Site Address: 1711 E YOSEMITE City: MANTEC'A Facility.Contact Person: MVI' Contact Phom Ma1(e.,Mi)del ell'Mt)nitorin4a System: TLS350_ _ _ Date of.I stinz'Servicing: 5/16/2013 B. inventory of Equipment Tested/Certified rank 1D.-ID:�TI -87-2 Tank ID: T3 87-2 _ fn=fmtk e.inuguaa Vrssha. Model: MAG' ®In-tank Gauging Prohc, Model: MAC Annular Still&Or Vault Senior. Mtatlel: 409 Q Annuhu,Space of Vattll Sensor. Model 409 i ®Pipin,gx+arnp: LraaehSan4ntts) Model 323 pilling 5amp,`'Irelic!"i4ot"s). Model: 323 0 Fill Sump Scnsons) Model: 208 hill Sunlit Sensorls). \IcKi(1: :08 ❑'tiMcchartuml Lina Leak rmector. %xkq: _ ❑S•tty huntwl Lina Leak tktccior. Model: ®l lectmoic I inc )cak Dctacma Model: PLLD ❑t lt'ctronrt fine teal,lk-,ector. kim-del: ®Tart) ()eertt)I l li,�h•I etci 4anwar. Model: UW ALAIil1 ®"9ank Overfill;ttith 4,ctcl San.,u: Model: E:\1 1LARNt El Other ther tspccah equipnmil hlw�and ntodet in Section Uon Page 2.). ❑other(spccill.cgttipment type and n idol in Secnana f on Pas e'). Tank ED '1`3-91 Tank IQ: _ _ 9 In lank tiaugutg t'rtda Model: MAG ❑in=fank(;auging Probe. VMtsdel: — ®Annular Space or Vault Scrimir, Model: 409 ❑Annular Space tar Vault Seowr. Model, ®Patten Sump I rcneh Scttsorts). Modal- 323 ❑Piping Sump!Trench Scnwrts). ttx(lel: Fill yuntp tivas sr(,r. Mtsdcl 20323 ❑t ill!Sump Sensogs(. Mmel' )j o kicclt uuc tl Late Leak Dttc'hex Model: LD2000 Q Mechanical IJoe Leal;Docclor. 1(xkt ❑Ficcuom;;[.file l.cak.DOcenir, Madel: -^ ❑(:Icctrontc Line 1•(:ak Chtector, Model: ® Tankoverfill l lith-1 etel Sensor Modcl' txr \LARNI Lj 1 ank t itetfill,"Night Ixteh Sen cq Model: ❑C)thrcr ispc%:jk equipment h pa and nxadel in Section['oil Page 2 i. ❑Other(spcciR equipmenttype and n dei in tic-clion F on Pa fte.2). Dispenser ll): V2 Dispenser ID: 3/4 rser ❑D(s res r t imt;nnma t 1 ksaU'r)uttd mad`i�)323 Shear Valve(s).(seta nnautt senvnr(a) hadcE' 323 Sheaf 1ha::if'xrnlYi(S). ❑ l er C ontainin�tt Float(.)and "haints) Dispenser 11) {,* - Dispenser ID: 7..18 0 Dispenwr C ontainnmo Sen,titi o. Model: 323 ®i)ispenur C'ontnintnent sensori"). oilcl: 323 i ©c Shear\'altct,r. 0 5hearVaktls). G ❑Dispensci C,artanaliciit I hlawo findChain(s). ❑t)ispen,er Containment Ftoat(,)anis C;haitntsa � Dispenser ID,� Dispenser ID: []I)iapattacr t'untoinmssu Senwns). Model: ❑t)izpenseK(:'t,n[rxinment Sensnr(,) 1.110 o.. w [:].Shear\ahcc( t ❑4ttc•tr\'nht.(ti) ❑Disputscr C,otaintncnt Floal(s)and C bain(s). ❑I haps nscr C untainnicnt Ilouwo and( h(fats(. Check the sippropriate bows to iodicaste specific egnipaocnt hisgected/serviced: 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 infitrination (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Phan showing the layout of monitoring equipment. For any equipment capable of generating such reports.I have also atCtched a copy of the report;(check all ffix unit),): 0 System Set-up .i Alarm history report 'J"m1 )iciat)'Name(print): KELVIN CRUZ ....... Signature: -- Cet'tilication A22519 Licenser No.: 433159 Testing C ompat» Name: 0.Z.Service Station Maintenance _ Phone No.: (916) 371-2380 Site 1011 Triangle Court West Sacramento,CA 9-%05 fate of TestingiServiciti : 4/1612013__µ_ +'V't(mitot-inv.Ce=rtification-hest Report I of 4 ......... _ ._ _ ................................. .._.._.