COMPLIANCE INFO_2011-2015 - Laserfiche WebLink

Home Browse Search

Appendix VI riEGEIVEU MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California FFB 2 7 2015 Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23, California Code of Regulatibn 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 to NMENTAL Owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days=s t . A. General information: Facility Name: BEN HOLT ARCO Bldg.No.: Site Address: 2908 WEST BEN HOLT City: STOCKTON CA Zip: Facility Contact Person: Lawrence Wight Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 360 Date of Testing/Servicing: 1/29/2015 B. Inventory of Equipment Tested/Certified Check the approEnate boxes to indicates ecific equipment ins ected/serviced: Tank ID: 87 Tank Size: Tank ID: 87 SLAVE Tank Size: ® in-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sensor(s). Model: 323 ® Piping Sump/Trench Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: PLLD ❑ 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 Tank Size: Tank ID: VAPOR POT Tank Size: ® in-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor. Model: 420 ® Piping Sump/Trench Sensor(s). Model: 323 ® Piping Sump/Trench Sensor(s). Model: 323 ® Fill Sump Sensor(s). Model: 323 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: 99 LD2000 ❑ 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: HIGH LIQ 420 ❑ 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 ® Dispenser Containment Sensor(s). Model: 323 ® Dispenser Containment Sensor(s). Model: 323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 ID Dispenser Containment Sensogs). Model: 323 ® Dispenser Containment Sensor(s). Model: 323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: PROD TRAN BOX Dispenser ID: ❑Dispenser Containment ® Dispenser Containment Sensor(s). Model: 323 Sensor(s). Model: ❑ 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-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): David Winkler Signature: Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2" STREET GALT CA 95632 Date of Testing/Servicing: 1-29-2015 Monitoring System Certification It Page 1 of 4 2/21/07