COMPLIANCE INFO_2006-2018 - Laserfiche WebLink

Home Browse Search

0 Appendix VI MONITORING SYSTEM CERTIFICATION 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 Codf ns This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared fo R I each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tank system ED 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 FEB 19 2014 Facility Name: RIPON SHELL Bldg.No.: Site Address: 341 EAST MAIN ST City: RIPON Zip:ENVIRDIWNTAS. HEALTH Facility Contact Person: ANGLE Contact Phone No.: (209)599-4454 PEW RVICES Make/Model of Monitoring System: VEEDER ROOT TLS350 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the aperoeriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: 87 Tank ID: 91 ® In-Tank Gauging Probe. Model:MAG 1 ® In-Tank Gauging Probe. Model MAG I ® Annular Space or Vault Sensor. Model:302 ® Annular Space or Vault Sensor. Model: 302 ® Piping Sump/Trench Sensor(s). Model:208 ® Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model:P L L D ® Electronic Line Leak Detector. Model: P L L D ❑ 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). TanklD: TanklD: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: jR Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: L I 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: 3 / 4 ® Dispenser Containment Sensor(s). Model: 322 ® Dispenser Containment Sensor(s). Model: 322 ® Shear Valve(s). ® 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 ® Dispenser Containment Sensor(s). Model: 322 ® Dispenser Containment Sensor(s). Model: 322 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(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 aft that apply): ®System set-up ®Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: 5263327-UT CA UTT2206 Nevada UST26755 Oregon License No: 04-1676 CA 2206 Nevada 26755 Oregon Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2" STREET GALT,CA 95632 Date of Testing/Servicing: 1-22-14 Monitoring System Certification Page 1 of 4 2/21/07