COMPLIANCE INFO_2013-2017 - Laserfiche WebLink

Home Browse Search

UNIT RING SYSTEM CETIIC IQN 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 of :Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system 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 Facility Name: CRUX #5446 Bldg. No.: Site Address: 1403 COUNTRY CLUB BLVD City: STOCKTON Zip: 95204 Facility Contact Person: ALLEN FAASS Contact Phone No.: (925) 884-0800 Make/Model of Monitoring System: VEEDER-ROOT TLS -350 Date of Testing/Servicing: 5/12/2015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific quipment inspected/serviced: Tank ID: DIESEL Tank ID: 87 N In -Tank Gauging Probe. Model: VR MAG N In -Tank Gauging Probe_ Model: VR MAG N Annular Space or Vault Sensor. Model: VR 302 N Annular Space or Vault Sensor. Model: VR 302 N Piping Sump / Trench Sensor(s), Model: VR 208 N Piping Sump / Trench Sensor(s). Model: VR 208 ❑ Fill Sump Sensor(s). Model: 1771 fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 N Mechanical Line Leak Detector. Model: LD2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Oveifill / High -Levet Sensor. Model: FLAPPER / MAG ® Tank Overfill / High -Level Sensor. Model: FLAPPER 1 MAG ❑ 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: 91 Tank ID: N In -Tank Gauging Probe. Model: VR MAG ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 302 ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: VR 208 ❑ Piping Sump/ Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High -Level Sensor. Model: FLAPPER / MAG ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section F on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). 112 Dispenser ID: 314 ntainment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: EDispenser ). NShear Valve(s). ntainment Float(s) and Chain(s). N Dispenser Containment Float(s) and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ❑ 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). 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 aqui went capable of generating such reports, 1 have also attached a copy of the report; (check all that apply): ® System set-up Alarm history report Technician Name (print): RICHARD THOMAS Signature: I _ 'A --S Certification No.: 5012133701 License. No.: 803705 Testing Company Name: TANK TEK ENVIRONMENTAL CORPORATION Phone No.: (707) 779-4999 Testing Company Address: P.O. BOX 5850, RIVERSIDE, CA 92517-5850 Date of Testing/Servicing: 5/12/2015 Page 1 of 4 UN -036 — www.unidocs.org Rev. 01/17/08