COMPLIANCE INFO_2011-2014 - Laserfiche WebLink

Home Browse Search

Monitoring Certification For Use lay 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 perforans 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 system within 30 days of test date. A. General information Facility Name: Chevron Bldg.No.: Site Address: 1103 S. Main St City: Manteca, CA Zip: 95337-5743 Facility Contact Person: Manager Contact Phone No.: (209)825.0174 Make/Model of Monitoring System: V1R TLS-350 Date of Testing/Servicing; 1119/12 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID•01-Prem Tank ID• 02-Regu ❑ in-Tank Gauging Probe. Model: VR 847390407 ❑ In-Tank Gauging Probe. Model VR 847390.107 tg Annular Space or Vault Sensor. Model: VR 794390.409 Annular Space or Vault Sensor. Model: VR 794390-409 19 Piping Sump\Trench Sensor(s). Model: VR 794380-208 Piping Sump\Trench Sensor(s), Model: VR 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Linc Leak Detector, Model: N Electronic Line Leak Detector. Model: VR series 8484 ❑ Electronic Linc 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• 03-Regu Tank ID: ❑ in-Tank Gauging Probe. Model: VR 847390.107 (3 In-Tank Gauging Probe. Model: N Annular Space or Vault Sensor, Model: VR 794390.409 ❑ Annular Space or Vault Sensor, Model: N Piping Sump\Trench Sensor(s). Model: VR 794380.288 ❑ 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: N Electronic Line Leak Detector. Model: VR series$484 ❑ Electronic Line Leak Detector. Model: ❑ Tank.Overfill\High-Levcl 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 01-02 Dispenser ID: 03-04 S Dispenser Containment Sensor(s). Model: VR 794380.208 ® Dispenser Containment Sensor(s). Model: VR 794380.208 ® Shear Valve(s). 3 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment float(s)and Chain(s). Dispenser ID- os as Dispenser ID• 07.08 ig Dispenser Containment Sensor(s). Model: VR 794380.208 ® Dispenser Containment Sensor(s). Model: VR 794380208 X Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID• 09-10 11.12 p Dispenser ID- 0 Dispenser Containment Sensor(s). Model VR 794380.208 ® Dispenser Containment Sensor(s), Modcl; VR 7943110.218 19 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 manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'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; (cheek all thatapptv); ® System set-up 50 Alarm history report Technician Name(print): Randy Wilkerson Signature: L�, _ Mfg.Cert.#.: A32404 ICC# 5258560-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave,,San Jose, CA 95112 Date of Testing/Servicing: 1119/12