COMPLIANCE INFO_1996-2008 - Laserfiche WebLink

Home Browse Search

MONIPORING SYSTEM CERTIFIRATION For y I Ju lctions i in a to of California Authority Cited-Chapter 6.7, Health and ety e;Chapter 1 , Division 3, rde 2 , California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A g&oarage c"flcafion must be Dipperedfor each gMkftsystemy the technician o performs the work. A y 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 F Wilson a Chevron B'd° "° s+4® 437 N.Wilson a Stockton 95205 Fadifty Contact P G /Owner Contect Phone No.: 209 942-2344 MakefflodelofM system: Veeder RootTLS 350 Date of11/16/2006 S. Inventory of Equipment Tested/Certified c Tank ID:UnleadA Tank ID:Premium •In-Tank Gauging el:MvgngaWg&v 0 In-Tank Gaging Probe. Model: e •Annular Space or Vault Sensor. Model:794320-407 0 Annular Space or Vault Sensor. Model:7943204Q7 Piping Sump/TrenchSensor(s). el:7 Piping Sump/Trench Sensor(s). el:7 Fill Sump Sensor(s). el: 3 Fill Sump Sensor(s). l: Mechanical Line Leak Detector. Model:FE LD Mechanical Line Leak Detector. el:Red Jacket FiV Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Tank Overfill/High—Level Sensor Model: Tank Overfill/High-Level Model: (specifyEl Other ui t and model in Section E on LPaZe t. Ot t and model in E on Page 2. Tank 1D: Tank ID: In-Tank Gauging Probe. el: 0 In-Tank Gauging Probe. Model: Annular Spam or Vault Sensor. Model: El Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/Trench (s). Model: ❑Fill Sump (s). Model: C1 Fill Sump (s). Model: ❑Mechanical Line Leak Detector. Model: D Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. odea: Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor Model: 0 Tank Overfill/Hig e!Sensor Model: ❑Other ui and model in Section E on Page 2). Other(!e2a equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID:% Dispenser WainmentSensor(s). Model:Veeder Root 32012M1 0 Dispenser C�—MainmentSensor(s). el:V Root 32012-001 Shear Valve(s). Shear Valve(s). D set Containment Float(s)and Chains. D' 'nm F t s and Chain(s). Dispenser ID:5/6 Dispenser ID:7/8 Dispenser Containment (s). Model:Veeder Root 32012-001 Dispenser Containment s). Model:V R 32012 1 Shear Valve(s). Shear Valve(s). El Dispenser Containment F s and Chains. ❑Dispenser Contain s and Chaln s. Dispenser ID: Dispenser ID: ❑Dispenser Contain Sensor(s). Model: Dispenser Containment (s). Model: El Shear Valve(s). Shear Valve(s). ' anser Containment Float(s)and Chaln s. Float(s)and Chain(s). *—If the fadlitycontaffis mom tanks ordAoensefs,copy this fbim Indude Iftimawn for evvy tar*and okspenserat the fadlity C.Certification-I certify that the equipment identified in this document was inspected/serviced inspected/servicedin accordance with the manufacturers' guidelines. Attached to this Certification is the information(e. .manufacturers! )necessary to verify at this information is correctand a Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attach of the report; CoAbck all that a §ystern set-uphisto Mort Technician (print): Kevin R. Matlock S' lure: ICC Cert' tion 5069874-UT License: S R 2-1633 Testing Company Name: C)mpliance Solutions, Inc. I Phone No.: 769-5215 Address: P.O. o 3917, Merced CA 95344 Date of T in : 11/16/2006 Page 1 of 3 OW Monitoring stem Certification