COMPLIANCE INFO_2010-2018 - Laserfiche WebLink

Home Browse Search

Appendix MONITORING SYSTEM CERTIFICATION RECEIVED For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of JUN Regulations 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 tank system I owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General information Facility FLAME LIQUOR CHEVRON Bldg. No.: Site AddfeCs• 1301 W KETTLEMAN LANE City: LODI CQ Zip: Facility Contact Parcnn• RUPI Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 6/13/2011 B. Inventory of Equipment Tested/Certified Check the annronrlate bores. to indicata s.pacific equipment Inspected/serviced: Tank ID: 87 Tank ID: 91 E In -Tank Gauging Probe. Model: MAG 1 E In -Tank Gauging Probe. Model: MAG 1 E Annular Space or Vault Sensor. Model: 420 E Annular Space or Vault Sensor. Model: 420 E Piping Sump / Trench Sensor(s). Model: 208 E Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: LD 2000 E Mechanical Line Leak Detector. Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ 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). ID: DSL Tank ID: NA liank In -Tank Gauging Probe. Model: MAG 1 ❑ In -Tank Gauging Probe. Model: %•',.❑ Annular Space or Vault Sensor. Model: SPLIT W 91 ❑ Annular Space or Vault Sensor. Model: E Piping Sump / Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: FXIV - D ❑ 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: ❑ 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: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ ShearValve(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): DAVE WINKLER Signature: Certification No.: 5263373 -UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2 STREET GALT CA 95632 Date of Testing/Servicing: 6-13-11 Monitoring System Certification Page 1 of 4 2/21/07