COMPLIANCE INFO_2013-2018 - Laserfiche WebLink

Home Browse Search

MONIT08ING SYSTEM CERTIFOATION ' ["%J -1 v L MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 AUG 0 5 2015 CERTIFICATION /TEST DATE: Jul 30, 2015 A1. FACILITY INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to indicate equipment Inspected/serviced) 131: TANKS A2. OWNER LJ;:AITu rwD6v0 A8P^I Name Quik Stop Market #144 Name Quik Stop Markets, Inc. Address 7272 West Lane, Stockton, CA 95210 Tank #1 (Product): Gasoline - 87 ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Phone # 510-657-8500 Contact Roger Barta Model: Model: Model: Model: Model: Model: Model: Model: contact Debbie Markovich A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified July 14, 2015 Lic # 617238 A, B, Haz Inspector Fatinah Zareef Dispenser # : 3-4 ■ Dispenser Containment Sensor(s) ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Contact Veronica Freitas Phone # 209-468-8257 Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to indicate equipment Inspected/serviced) 131: TANKS Tank #1 (Product): Gasoline - 87 ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Tank #2 (Product): Gasoline - 89 ❑ In -Tank Gauging Probe ■ Annular Space or Vault Sensor ■ Piping Sump / Trench Sensor(s) ❑ Fill Sump Sensor(s) ■ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment in Section E) Model: Model: 0794390-409 Model: 0794380-208 Model: Model: Red Jacket FX Model: Model: Model: Tank #3 (Product): Gasoline - 91 ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 _ ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Tank #4 (Product): _ ❑ In -Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Piping Sump / Trench Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment in Section E) Model: Model: Model: Model: Model: Model: Model: Model: B2: DISPENSERS/UDC's j I Dispenser # : 1-2 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chains) Dispenser # : 3-4 ■ Dispenser Containment Sensor(s) ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Model: 0794380-208 Dispenser # : 5-6 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chains) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) -- 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 Pian 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 ■ Alarm History Report Signature: 0U. � Wil— WALTON ENGINEERING, INC. I I Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: July 30, 2015 I I T