COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

• • RECEIVED Monitoring System Equipment Certlificat1*01RAY 18 2015 For Use By All Jurisdictions Within The State of California ,4 ufhoritv Cited: Chapter 6 7, flealth and Safety Code; Chapter 16, Division 3, Tille 23, Calffiornia Coo E"ONMENTAL This forth must be used to document testing and servicing of monitoring equipment. A §cpara A,e certifica g lion or RE&RDHAMUNT prepared for each monjLQring system control pand 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 system within 30 days of test date. Facility Name: Unocal Bldg. No.: Site Address: 27131 March Ln. City: Stockton, CA Zip: 95219 Facility Contact Person: Manager Contact Phone No.: (209) 473-7337 Make/Model of Monitoring System: VR TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 4123/15 — Tank [D- 01-R69o' Tank IQ; 02 -Prem ❑ In - Tank Gauging Probe, Model: VR $47390-109 ❑ In - Tank Gauging Probe. Model: VR 847390-109 ❑ Annular Space or Vault Sensor, Model: VR 794390-420 ❑ Annular Space or Vault Sensor, Modcll VR 794390420 tj Piping Sump '•. Trench Sensor (s). Model: VR 794380-200 C] Piping Sump \ Trench Sensor (s) Model: VR 794380-208 [] Fill Sump Sensor (s). Model: 0 Fil I Sump Sensor (s). Model: 0 Mechanical Line Leak Detector. Model: Vappriess LD2000 0 Mechanical Line Leak Detector. Model: Va ortess LD2000 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector, Modell 0 Tank Overfill \ High -Level Sensor. Model: VR 790091-001 [] 'rank Overfill \ I ligh-Level Sensor. Modell VR 790091-001 0 Other ( specify equipment type and model in Section E on Page 2), C] Other ( specify equipment type and model in Section E. on Page 2), Tank I .03-0hasel Tank IQ: 0 In - Tank- Gauging Probe. Model: VR 646400.001 [3 In - Tank Gauging Probe. Model: [I Annular Space or Vault Sensor, Model: VR 744390-420 0 Annular Space or Vault Sensor, Model n Piping Sump " Trench Sensor (s) Model: VR 794380-208 n Piping Sump \ Trench Sensor (s), Model: 0 Fill Sump Sensor (s), Model: 0 Fill Sump Sensor (s), Model. 0 Mechanical Line Leak Detector. Model 'RJ 116-063.6 El Mechanical Line Leak Detector, Model: [I Electronic Line Leak Detector-, Model: El Electronic Line Leak Detector, Model: 0 Tank Overfill \ High -Level Sensor. Model: VR79009"01 [] Tank Overfill \ High -Level Sensor, Model: 0 Other ( specify equipment type and model in Section E on Page 2), 0 Other ( specify equipment type and model in Section E on Page 2). Dispenser In! 01-02 Dispenser ID: 03-04 0 Dispenser Containment Sensor (s), Model: ❑ Dispenser Containment Sensor (s). Model: 0 Shear Valve (s). ❑ Shear Valve (s). 0 Dispenser Containment Float (s) and Chain (s), 0 Dispenser Containment Float (s) and Chain (s). Dispenser 10: 05-06 Dispenser IQ; 07-08 0 Dispenser Containment Sensor (s), Model: [3 Dispenser Containment Sensor (s), Model: 0 Shear Valve (s), ❑ Shear Valve (s) 0 Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s), Dispenser IQ: 09-10 Dispenser ID: 11-12 0 Dispenser Containment Sensor (s), Model: [3 Dispenser Containment Sensor (s). Modell 0 Shear Valve (s), ❑ Shear Valve (s), 0 Dispenser Containment Floats) and Chain (s). ❑ Dispenser Ceiitaitirriciit]Tloal(s)and Chain (s), *If the facility contains more ranks 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 manufacturer's guidelines. Attached to this Certification Is Information (e.g. manufactures' checklists ) necessary to verify that this information is correct and a Plot Plan showing the layout oftnimitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the; (check all thatapply): [I System set-up 0 Alarm history report Technician Name (print): Raamon Frazier Signature: Mfg. Cert.#. icc# 8020732 -UT License, No.: 485184 Testing Company Name: Service Station Systems Phone No,:_�40 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 4123/15