COMPLIANCE INFO_1996-2005 - Laserfiche WebLink

Home Browse Search

10/19/2003 16:22 4089710 35 SSS INC PAGE 02 Monitoring ste Equipment Pi Cati For Use Ay All Jairisdictions Within The Stine ofCalifornia Al.ith.ority Cited: Chapter 6.7. Health.and Safety Code; Chapter 16,Division 3. Title 23, California. Code of Regulations This form lt).ust be used to document testing and servicing of monitoring equ.ip117ent. A se crate certification or re ort must be prepared for each monilori.n s stem control panel by the technician who performs the work.A copy of this forni must be provided to the tank system?owner/Cfg.UscrNa.l-ne. The owner/Cfg.UserName must submit a copy of this form to the local agency regulating UST 5y: within 30 days of test date. A. General Information Facility Narrtn: F2I on Sheil Bldg.No.: Site Address: 341E Main St @ Hwy. 99 City: Ripon, CA Zip: 95366 Facility Contact Person: David Contact Phone No,; (2001 599-4454 Make/Model ofMonitonAg System: V/R Simplicity Date of Testing/Servicing: 8128103 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank 1 -01 -Regu Tank ID: 02-Prem 9Q In-"Punta Gauging Probe. Model: VR 847990.109 IN In-Tank Gauging Probe. Model: vRa4739o•t09 0 Annular Space or Vaulr Scnsor, Model: VR 794380-302 29 Annular Space or Vault Sensor, Model: VR 754380.902 99 Piping Sul11p t Trench Sensor W. Model: VR 734380•208 M Piping Sump\'t'ranen sensor(s). Model: vR reaaae-zea ❑ Fill Sump Sensor(S). Model: Nona ❑ Fill Sump Sensor(5)- Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Dctuctur. Model: None 13iCctronieLine LeakDetector. Model: VRSadas3484 Qil 1.ICc1r0nlGLine LcakDCW9lui. Mpd�l: VRBarroa4484 ❑ Tank Ovcrlilt\High•LCvc1 Sensor, Model: None ❑ Tank.Overfill l Iligh-Level Sensor. Model: None p Other(speci:ry equipnxnt type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E-on.Paga 2). Tank I1)• Tank IDa p Cn•Tank Gauging Probe. Model: ❑ in-Tank Ganging Probe. Model rliiiiulut iNdGG or Vault Scn3or, Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump\Trench Seism-(s). Model: ❑ Piping Sump 1 Trench Sensor W. Model: ❑ bill Sump Scnsor(s). Model: ❑ Fill Sump Sensor(s). Model: p Mauhanical Line Leak Detector. milde:L' ❑ Mechanical Line Leak Detector. Model:,- ❑ Electronic Linc Leak Detector. Model: ❑ Electronic Linc Leak Detector. Mode' ❑ Tank Overfill\High•Lcvcl Sensor. Model: ❑ Tank Ovcrrill',Iligll-Level Sensor. Model: ❑ other(soecity equipment tVae and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser iD• 01-02 Dispenser ID• 03-04 ® Dispenser C.ontainmeni Sensor(s), Model:_ VR 794380.321 Dispenser Contailrncnt Scnsor(s). Model: VR 794384.321 Shear Valve(S). QQ Shear V;rlvc(o)• q Dispenser Containment Float(s)and Clain(s). ❑ Dispenser Containnent Float(s)and Chain(s). Dispenser 1D 05-06 Dispenser ID,.07-08 a I)ispenser Colltaipenc'nt Scnsor(s). Model: VR734380.321 29 Dispenser C:ontatnment Scnsor(s). Model: VR 7549Eo•szt R9 Shear Valve(s), 9 Shear Valve(s). n Disoenscr Containment Flo' (S)and Chain(s), ❑ 13isperlser Colltaillmcnt Float(s)and Chain(s). Dispenser ID• Dispenser 11)• 13 Di%pe,tser Containment Scnsur(s). Model: ❑ Dispenser Containment Scnsur(s). Model: ❑ 9hem Valve(a). ❑ Shoar Velvr(c) ❑ Dispenser Colmitltllent Float(s)and Chain(s). p Dispenser Containment Float(s)and Chain(s). *Jf the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility C. Certification- 1 certify that the equipment identified in this doetltllent was inspected/serviced in accordance with the manufactur-er'S g0idelinex. Attached to this certification is information(e.g.manufactures'checklists)necessary to verify that this information is correct and a Plat Plan showing the layout of monitoring equipment, For any equipment capable of generating such reports.t have also attached a copy of tile; (check all drat apply): ❑ System set-up ❑ Alarm hlstnry report Tecimician Name(print): SSS•R0 nW Signature: Original on file at SSS Certification No.: 290-62-0088 license.No.: 485984 Testil)g Company Name Ser.Sta.Sys. _Phone No.: (408) 971-2445 _ Site Address 341 E. Main St.2 Hwy.99 Date of Testing/Servicing: 8128/03