COMPLIANCE INFO_2010 - Laserfiche WebLink

Home Browse Search

ONI G SYSTEM CE TI 4ATIO � For Use By All Jurisdictions Within the State of California OP1114 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: Tracy Truck Stop Bldg.No.: - Site Address: 3940 N Tracy Blvd City: Tracy Zip: 95304 Facility Contact Person: Debbie .lutla Contact Phone No.: 209-832-5006 Make/Model of Monitoring System: Veeder-Root TLS 350 Date of Testing/Servicing: 04/02/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 1 - 87 Tank ID: 2 - 91 0 In-Tank Gauging Probe. Model: MAG 0 In-Tank Gauging Probe. Model: MAG x❑ Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: Split with 1 • Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 99 LD 2000 10 Mechanical Line Leak Detector. Model`. 99 LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify a ui ment a and model in Section E on Pae 2). ❑ Other(specia equipment a and model in Section E on Pae 2). Tank ID: 3 — Diesel / High flow STP also Tank ID: 4 - Diesel • In-Tank Gauging Probe. Model: MAG 0 In-Tank Gauging Probe. Model: MAG • Annular Space or Vault Sensor. Model: 420 Z Annular Space or Vault Sensor. Model: 420 O Piping Sump/Trench Sensor(s). Model: 208 / 208 2 Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑x Mechanical Line Leak Detector. Model: LD3000 / 99LD2000 rx1 Mechanical Line Leak Detector. Model: LD 3000 ❑ 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 t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pa a 2). Dispenser ID: 1 - 2 Dispenser ID: 3 - 4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑x Shear Valve(s). ❑x Shear Valve(s). ❑x Dispenser Containment Floats and Chain(s). 9 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 - 6 Dispenser ID: 7 - 8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: N Shear Valve(s). © Shear Valve(s). Z Dispenser Containment Floats and Chain(s). O Dispenser Containment Float s)and Chains . Dispenser ID: 11A Dispenser ID: 11 — 12A ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑x Shear Valve(s). ❑x Shear Valve(s). ❑x Dispenser Containment Float(s)and Chain(s). Z 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): IE System set-up ❑x Alarm history report Technician Name(print): Keith Huston Signature: Certification No.: A25577 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, LLC Phone No.: 888-700-EPIC Testing Company Address: 1001 Bayhill Dr, Suite 150 Date of Testing/Servicing: 04/02/2010 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidoes.org