COMPLIANCE INFO_1991-2008 - Laserfiche WebLink

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_ �� `t STATE LICENSE No. 323417 QIL CLASSIFICATION: A -RAZ., C6111140 Division of Keith A. Tallia, STA&NVIRONMENTAL ASSESSOR No. 01781 Telephone: (209) 7541808 Fax: (209) 7645726 Post Office Box 950 750 Industrial Way SAN ANDREAS, CALIFORNIA 95249 This form must be used to document testing and servicing of' monitoring equipment. If more than one monitoring system control panel is installed at the facility, 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. Instructions are printed on the back of this page. A. General Information Facility Name: Norms -76 Site Address: 633 E. Victor Rd. Facility Contact Person: Gr Make/Model of Monitoring System Wilson Veeder Root TLS250 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate City: Lodi Bldg. No.: Zip: 95240 Contact Phone No.: ( 209 ) 367-1795 Date of Testing/Servicing: 6 / 8 /01 Tank ID: T1 Super Tank ID: T2 Plus ModeCi �1 290-301 �l In -Tank Gauging Probe. Model:? 81 2 9 0 — 3 O 1 W In -Tank Gauging Probe. Model: RSDF A3 Annular Space or Vault Sensor. ModeiRSDF §l Annular Space or Vault Sensor. X:I Piping Sump/Trench Sensor(s). Model: 794'100-205 0 Piping Sump/ Trench Sensor(s). Model: 794300-205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: )l Mechanical Line Leak Detector. Model: R-111 16-0-56 W Mechanical Lane Leak Detector. Model: R T 116 — Q 5 6 ❑ Electronic Line Leak Detector. Model: _ b_e_Tank ❑ Electronic Line Leak Detector. Overfill !High -Level Sensor. Model: Model: 6_1S 0 r T_Uhe- X7 Tank Overfill / High -Level Sensor. Modcl: 61_S OD_ropT_ Model: ❑ Dispenser Containment Sensor(s)_ Model: ❑ Dispenser Containment Sensor(s) __ ______.__ M Shear Valve(s). X] Shear Valve(s). XO Dispenser Containment Float(s) and Chain(s). M Dispenser Containment Float(s) and Chain(s). 2). ❑ Other (specify a ui ment type and model in Section E on PaSe 2). ❑ Other (specify equipment t pe and model in Section E on Paee Tank ID: T 3 Re Tank ID: Model: 7 1n -Tank Gauging Probe. Model 7.8,_2..4.0— 301 L] In -Tank Gauging Probe. Model: XD Annular Space or Vault Sensor Model: RS_DF _ ❑ Annular Space or Vault Sensor. Model: 1 Piping Sump/Trench Sensor(s). vtodci: 7 9 d 1(1 0 — 2 0-5 ❑ Piping SumpiTrench Sensor(s). — Model: 1 ❑ Fill Sump Sensor(s). Model: _ _ _ _ ❑ Fill Sump Sensor(s)_ Model: •X0-7 Mechanical Line Leak Detector Modcl: RJ1 16-048 C3 Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. Model: ___. ❑ Electronic Line Leak Detector. Model: x❑ Tank Overfill / High -Level Sensor. Model: _61_SODropTube_ ❑ Tank Overfill / High -Level Sensor. Model: ❑ Dispenser Containment Scnsoro) Model:❑ Dispenser Containment Sensor(s) Modcl _ --.— x❑ Shear Valve(s). X❑ Dispenser Containmcat r loai(s, and (h:.m(s). ❑ Shcar Vak c(s). I D Dispenser Containment Floai(s) and Chain(s)_ Cl Other (specify equipment type and modrl in Section E on Paee') i� Other (specify equipment type and model in Section E on Page 2). C_ Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines_ Attached to this Certific:+tion is information (e.g_ manufacturers' checklists) necessary to yerifv that this inforutation is correct and a Site Plan sh-Vink the layout of monitoring equipment. For any equipment capable of gencratinp sorb rrporis, 1 have also attached a cultr of the W/1"ek fill that appil): O S1'steni het up report; ❑Alarm history re hrclmician Name rim : James P. Hesketh__- CertJLic. No.: 6_0669 Signattue: `testing Companv Name Oil Equipment__Service________ C..-11 ,11-01 1'11"1 1