COMPLIANCE INFO_2013-2018 - Laserfiche WebLink

Home Browse Search

• 11kCkiVEL Monitoring System Equipment Certificatmal 8 2015 f'or Ilse Ay AU Jurisdictions Within Ae State of California Authority Cited: Chapter 6.7, Heallh and Safety Code; Chapter 16, Division 3, 7711e 23, California FAMPORMENTAL, I 11� Ki #r7NQ— This form must be used to document testing and servicing of monitoring equipment. A 5el2grate gerti fl L cation e prepared for each mogitgring, system control l2atiLl 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. A. General Information Facility Name: Mobil/Tesoro Bldg. No.: Site Address: 401 W. Kettleman Ln. City: Lodi, CA Zip: 95240 - Facility Contact Person: Manager Contact Phone No.: (209) 368-8787 Make./Model of Monitoring System: Gil EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced- Date of Testing/Servicing: 2118/15 — Tank ID: 01-Regu Tank ID: 02 -Prom 0 In - Tank Gauging Probe. Model: GBCO PA2650960200 El ]it - Tank Gauging Probe, Model GUCO PA2660960200 N Annular Space or Vault Sensor. Model-, VR 794390420 IM Annular Space or Vault Sensor. Model: VR 794390460 0 Piping Sump \ Trench Sensor (s). Modej: VR 794300.208 Do Piping Sump \ Trench Sensor (s), Model: VR 794380-208 [3 Fill Sump Sensor (s). Model: 0 Fill Sump Sensor (s). Model: Mechanical Line Leak Detector. Model: RJ 116-066.6 W Mechanical Line Leak Detector, Model: --- RJ 116-066-5 ❑ Electronic Line Leak Detector. Model: 0 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 11 on Page 2), C) Other ( specify equipment type and model in Section E on Page 2), Tank ID! rank I ; C) In - Tank Gauging Probe, Model: (I In -'rank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor, Model: C) Piping Sump \ Trench Sensor (s). Model: [I Piping Sump \ Trench Sensor (s), Model: C) Fill Sump Sensor (s). Model: [] Fill Sump Sensor (s). Model: Cl Mechanical [.me Leak Detector, Model: 0 Mechanical Line Leak Detector. Model: [3 Electronic Line Leak Detector, Model: [3 Electronic Line Leak Detector, Model: 0 Tank Overfill i High -Level Sensor, Model: (3 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 1 01-02 Dispenser ID., 03-04 0 Dispenser Containment Sensor (s). Model: [3 Dispenser Containment Sensor (s). Model: Shear Valve (s). IS Shear Valve (s). Dispenser Containment Float (s) and Chain (s), IM Dispenser Containment Float (s) and Chain (s), Dispenser - 05-06 Dispenser ID: 07-08 (j Dispenser Containment Sensor (s). Model: [] Dispenser Containment Sensor (s). Model: ag Shear Valve (s). jX Shear Valve (s), Cf Dispenser Containment Float (s) and Chain (s). I@ Dispenser Containment Float (s) and Chain (s). Dispe:nser ID: DisDispenser Dispenser IQ: CIDispenser Containment Sensor (s). Moi:16 C) Dispenser Containment Sensor (5). Model: Shear Valve (s). ShearViij: 0 Shear Valve (s), Dispenser Containment Float (s) and Chu in (s), 0 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 manufacturer's guidelines. Attached to this Certification is information (e.g. ruamilactures, checklists ) necessary to verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable ofgencrating such reports, I have also attached a copy of the; (check all tharapIdy): 0 System set-up 0 Alarm history report Technician Name (print): Kris Bell Signature: Mfg. Cert.#.: B33709 — ICC# 5297793 -UT License. No,: 485184 Testing Company Name: Service Station Systems Phone No.: (408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 2/18/16