COMPLIANCE INFO_2006-2009 - Laserfiche WebLink

Home Browse Search

U8/19/2008 09:25 831648 4 SPECIAL SER'JICE PAGE 02 Monitoring System Certification Por Use By Art Jurdsdlixions Wdhin the State of California AaMorMy Cited:Chapter 6.7,Health and Safety Code;Chapter 16,DAdsfon 3, 7FU9 23,Callfornis Coda of Regulations This form must be used to document testing and servicing of monitoring oquipmenL A rate Certlllcagon or m t must tae propared(or each monHoririg system control panel by the tachnician who peffotttas the work.A copy of Prov, ecT[3 i�igTiR ymee`m ownerli p3 motor. I ne awncN Me opefaKW mu3E'3i}bTMrT—W0Y of this form to the tical agency regulating LIST systems wlihin 3tJ dirt's o€test date. A. General Information Faclt : Pacfio Bell Telephone Co.dbe AT&T Califomla GEO PAR#UE020 Address. 124 W. ELM ST. City. LODI Zi :95242 Facility Contact Person:CONME MITCHELL E.S.M. Contact Phone No:209-474-4022 Make/Model of Monitoring System:VEEDER ROOT TLS-350 Service Date;07/30/2008 B.Inventory of Equipment Tested/Certifled check fuer opmpriato boxes to Indicate specific®qutpmmm®nt InspertedUservl«d: Tank ID:OUE02OU001 Tank ID: ❑In-Tank Gauging Probe Model: ©In-Tank Gauging Probe Model: ❑Annular Space or Vauft Sensor Model; ❑Annular Space or Vault Sensor Mode(: ❑Plping Sump/Trench Sensor(s) Model: ❑Piping Sump 1 Trench Sensor(s) Model: ❑Fig Sump Sensor(s) Modal: ❑Fill Sump Sensors) Model: ❑Mechanical tate Leak Detector Model: ❑Mechanical Line Leek Detector Modet. ❑Etectmnic Line Leak Detector Model: ❑Electronic Une teak Detector Model., ❑Tank Overfill/High Level Sensor Model: ❑Tank Overfill/High Level Sensor Modal., Other(Specify equipment type and model in Socdon E on Page 2) ❑Other(Specify equipment type and model in Section E on Page 2) Tank.ID: Tank ID: ❑In-Tank Gauging Probe Model: ❑In-Tank Gauging Probe Madel: ❑Annular Space or Vault Sensor Model: ❑Anrpjiar Space or Vault Sensor ❑f'rpin9 Sump/Trench Model; Sensors} Model: ❑Piping Sump/T'reruin Sensor(sy Model: ❑Flit Sump Sensors) Model; ❑Fn Sump Sensor(s) Model: 0 Mechanical Line Leak Detector Model: ❑Madtanicel Line beak Detector Model: ❑Electronic Line Leek Detedor Modal: ❑Eiedronlc tine Leak Detector Model: ❑ Tank Overfill/High Level Sensor Model; ©Tank Overfill/High Loved Senor Model: ❑Other(Spedfy equipment type and model in Section E on Page 2) ❑Other(Specify equipment type and model In Section E on Page 2) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(&) Monet: ❑Dispenser Containment Sensor(s) Model: ❑Shear VRive(s) ❑Shear Valve(s) ❑Dispenser Containment Float(s)and Chaln(s) ❑Dispenser Containment Flasks)and Chain(s) Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s) Model. ❑DISPer0w Containment Senso(s) Model: ❑Shear Velve(st ,_ ❑Shear Valves) ❑Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Float(3)and Chains) D�ITser ID: Dispenser ID; ❑Dispenser Containment Sensor(&) Model: ❑Dispenser Containment Sensor(s) Model, ❑Shear Valve(s) ®Shear Vatve(s) ❑Dispenser Containment Roat(s)and Choin(q) ❑Dispenser Containment Floats)and Chain(s) •If the facilkY contatr14 more tanks or dispensers,COPY this form.Include information for every tank and dispenser at the facility. C.Certification-I codify 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): Alarm history report Technician Name(Print): MICHAEL L. STRAWN II Si ature �— Certification o:VEEDER ROOT-A31215 License o:588098 Testing Company Name:TAIT ENVIRONMENTAL Phone No:(714)560-8222 !SERVICES Page 1 of 4