COMPLIANCE INFO_2007-2018 - Laserfiche WebLink

Home Browse Search

MONIT&UNG SYSTEM CE TION 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 Regulations This form must be used to document testing and servicing of monitoring equip W#' dearion or report must be prepared for each monitoring_Ustem control panel 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 tol the igMpgency regulating UST systems within 30 days of this date. A. General Information Facility Name: Yosemite 76 fwF R Nllil F), V1 CE Bldg. No.: Site Address: 1700 Yosemite Avenue City: Manteca Zip: 95336 Facility Contact Person: Amba Rai Make/Model of Monitoring System: Veeder-Root TLS -350 B. Inventory of Equipment Tested/Certified Check the Appropriate boxes to to specific equipment inspected/serviced: Contact Phone No.: 925-756-1210 Date of Testing/Servicing: 3/30/2007 Tank ID: 12000 gal. Regular Tank ID: 12000 gal. Super [X] In -Tank Gauging Probe. Model:847390-107 L] In -Tank Gauging Probe. Model: 847390-107 L] Annular Space or Vault Probe. Model:794380-420 N Annular Space or Vault Sensor. Model: 794380-420 C] Piping Sump / Trench Sensor(s). Model:794380-208 [x1 Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s). Model: [J Mechanical Line Leak Detector. Model: VM1 U Mechanical Line Leak Detector. Model: VM1 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: [X] Tank Overfill / High Level Sensor. Model: OPW 61 -SO [, Tank Overfill / High Leval Sensor. Model: OPW 61 -SO ❑ Other (specify equip. type and model in Sec. E on Pg. 2) ❑ Other (specify equip. type and model in Sec. E on Pg. 2) Tank ID: Tank ID: [] In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model:�� ❑ Annular Space or Vault Sensor. Model: p Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensors(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Decector. Model: M 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 equip. type and model in Sec. E on Pg. 2) ❑ Other (specify equip. typs and model in Sec. E on Pg. 2) Dispenser ID: 1 & 2 Dispenser ID: 3 & 4 ❑ Dispenser Containment Sensor(s). Model: 794380-208 [x1 Dispenser Containment Sensor(s). Model: 794380-208 Ex] Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ID: 5 & 6 Dispenser ID• 7 & 8 Cx] Dispenser Containment Sensor(s). Model: 794380-208 [X] Dispenser Containment Sensor(s). Model: 794380-208 (� Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Float(s) and Chains(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s). *It 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/services in accordance with the manufacturers' guidlines. Attached to this Certification is information (e.g. manufacturers' checklist) necessary to variify that this information is correct and a plot plan showing the layout of monitoring equipment. For equipment capable of generating such reports, I have attached a copy of the report; (check all that apply) x❑ System Set-up x Alarm hist ry report Signature: Technician Name (print): Kristopner ►tarns Ira"_4 rte Certification No: 834106 License No: 804904 Testing Company Name: Confidence UST Services, Inc. Phone No: 800-339-9930 Site Address: 1700 Yosemite Avenue, Manteca, CA 96336 Date of Testing/Servicing: 3/30/2007