COMPLIANCE INFO_1999-2009 - Laserfiche WebLink

Home Browse Search

May, 31, 2005 4:02PM-1v1k est Star Environmental, Inc. —L j— I "- ,%-,, L ,No, 5305 P. 2 MP Or Ube by All rurlsatcituris rr it run the State ANalifornia Authority Cite& ChapterW, Flealth and Safety Code; Chapter 16, Division it a 23, California Cade of Regulations This form must be used to document testing and seivicing of monitoring equipment A se crate ccrtificaticm<irre ort must be Prepare for each monitorin"system control Rapp by the technician who performs the work.A copy of this forret must be provided to the tan! system owner/operator.The owner/operator must submit a copy of this form to the local agency regulating LIST systems within Y days of test date. A.General Informatiott l;acility Name: ESCALON MINI MART Bldg.No.: , Site Address: 1097 F._YOSEMITE City; ESCALON Zip: 95320 Facility Contact Person:BILL Contact Phone No.: ( 209 1 838-1546 Make/Model of Monitoring System: AUTO S'FiC1K M(F,BW) Date of'resting/Servicing: 05 /11 /05 B.Inventory of Equipment Tested/Certified Cheek the appropriate boxes tr,indicate specific cgvipmeet inspeeted/srrviced: 'rank 11.0-UNLEADED Tank ID-PREM ❑In-Tank Gauging Probc_ Model: L]in-Tan�uging Probe. Model: _ ❑Annuiar.Space or Vault Sensor. Model, ❑Annular Space er Vault Sensor. Model: Q Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill IS Sensor(s). Model: Q Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic cine Leak Detector. Model: w _ ❑Electronic Line Leak Detector. Model:__._.,�..._. ❑Tank Overfill/High-Level Sensor.Model: ❑Tank Overfill/High-Level Sensor.Model: Otherec:if ui ment a and model in SLetion E on Pa e 2 . ®Others ui ment and model in Section E on P e 2). Tank ID: Tank ID' ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model:_ []Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: [�Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: L'lectronic Line Leak Detector. Model: ❑Electronic bine Leak Detector. Model: Tank Overfill/High-Level Sensor.Model: � Tank Over-fill/High-Level Sensor.Model: Other(s eeif ui ment Me and model in Section E on Pa e 2. Other�Zcj&a ui me it ty.211a.nd model in Section E on P e 2). Dispenser 1D Dispenser 1D: Dispenser Containment Sensor(s).Model: Dispenser Containment Sensor(s).Model: Shear Valve(s). Shear ValVc(s)_ - DI eraser Containment Roat s an anis. Dispenser Containment Floats an Chain(s) Dispenser 1D- Dispenser ID- Dispenser Containment Sensor(s). Model: _ ZI Dispenser Containment Sensor(s),Model: Shear Valve(s). Shear Valve(s). � Dis ensue Con "dtld(Mains. Di ens er Containment Float(s) and Chain(s).. ispeaser W- -,„ ❑ Dispenser Containment Scnsor(s),Model: Dispenser Containment Sensor(s).Model, ❑ Dispenser ID- Shear Valve(s). Shear Valve(s). _ Dispenser Containment Float(s)and Chain(s). DENspenscr Containment Float(s)and Chain(s). •If the%cility contains more tai.nks or dispensers,copy this form.Include information for every tank and dispenser at the Tacility. L. Certification-1 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 Piot 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 El ,Alarm his r report 'reclwieian Name(print): SQ1 JEQA Signature: Certification No.: 8922 _, , , .. License.No.: 60 42 Testing Company Name: West Star Environmental Phone Number- (559)277-9378 Site Address: 4655 W.Jennifer,Suite 101 / Fresno,CA 93722 ,,,—Date of Testing/Servicing: 05 / 11 /05 IvIolxitoring System Certification Page 1 of 4 03101