COMPLIANCE INFO_2009-2018 - Laserfiche WebLink

Home Browse Search

MON119MNG SYSTEM CERTIF TION 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 -rate certification or re ort musREQEIVED 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. MAR 0 4 2011 A. General Information ENVIRONMENTAL HEALTH Facility Name: Wilson Way Chevron Bldg. No.I ER IT/SE VICES Site Address: 437 N. Wilson Way City: Stockton, Ca. Zip: 95205 Facility Contact Person: Aman Mehroke Contact Phone No.: (209) 942-2344 Make/Model of Monitoring System: Veeder-Root TLS -350 Date of Testing/Servicing: 2/15/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: T1: 87 Tank ID: T2: 91 ® In -Tank Gauging.Probe. Model: 847390-109 ® In -Tank Gauging Probe. Model: 847390-109 ® Annular Space or Vault Sensor. Model: 794390-407 ® Annular Space or Vault Sensor. Model: 794390-407 ® Piping Sump / Trench 9ensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Mechanical Line Leak Detector. Model: VMI 99LD-2000 ®Mechanical Line Leak Detector. Model: R.J. FX1V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line 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: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ 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: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line 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). Dispenser ID: 1&2 Dispenser ID: 38x4 ® Dispenser Containment Sensor(s). Model: 330212-001 ® Dispenser Containment Sensor(s). Model: 330212 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 6&6 Dispenser ID: 7808 ® Dispenser Containment Sensor(s). Model: 330212-001 ® Dispenser Containment Sensor(s). Model: 330212-001 ® 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 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 Technician Name (print): Guadalupe Sanchez Signatures®` Certification No.: A30138 License. No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.: (209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca. 95361 Date of Testing/Servicing: 2115/2011 Page 1 of 4 Rev (2/08)