COMPLIANCE INFO_2011-2018 - Laserfiche WebLink

Home Browse Search

Ll .7 MONITORING SYSTEM CERTIFICATIOl 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 pf Regulations FEB 2 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepare or each monitoring_system control panel by the technician who performs the work. A copy of this form must be provided to the tank sTAtein owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test dale :ji1 A. General Information Facility Name: Shell Bldg. No.: Site Address: 16500 S. Harlan Road City: Lathrop Zip: 95330 Facility Contact Person: Nick Arbabian Contact Phone No.: (209) 983-0381 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 02/17/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauinment inspected/serviced: Tank ID: #1 Regular 12000 Gal Tank ID: #2 Premium 12000 Gal E In -Tank Gauging Probe. Model: MAGA E In -Tank Gauging Probe. Model: MAGA E Annular Space or Vault Sensor. Model: 794380-407 E Annular Space or Vault Sensor. Model: 794380-407 E Piping Sump / Trench Sensor(s). Model: 794380-208 E Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: E Mechanical Line Leak Detector. Model: Vaporless 99LD2000 E Mechanical Line Leak Detector. Model: Vaporless 99LD2000 ❑ Electronic Line Leak Detector. Model: ❑ 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 E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: ID: ElIn-Tank Gauging Probe. Model: FTank 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: ❑ 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: ❑ 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 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: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). E 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). $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 all that apply): ® Systemset-up ® Alarm history report K ` Technician Name (print): Nikola Zagorov Signature: 1 it Certification No.: Veeder Root Level 4 # A32784 License. No.: 958763 A " Testing Company Name: ECO-CHEK Compliance Phone No.: (888) 500-CHEK Testing Company Address: P.O. Box 77194 San Francisco CA 94107 Date of Testing/Servicing: 02/17/2012 Page 1 of 4 Rev (2/08)