COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

Monitoringtystem For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 6.7, Health andSafety 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 system within 30 days of test date. A. General Information Facility Name: Shell/Tesoro Bldg.No.: Site Address: 13975 E. Hwy 88 City: Lockeford, CA Zip: 95237 Facility Contact Person: Manager Contact Phone No.: (209)727-0823 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 8128118 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID•01-Regu Tank ID' 02-Prem ® In-Tank Gauging Probe. Model: VR 846390-111 ® In-Tank Gauging Probe. Model: VR 846390.111 X Annular Space or Vault Sensor. Model: VR 794380-301 Annular Space or Vault Sensor. Model: VR 794380-301 ® Piping Sump\Trench Sensor(s). Model: VR 857080-111 ffi Piping Sump\Trench Sensor(s). Model: VR 857000.111 ® Fill Sump Sensor(s). Model: VR 857080-111 ® Fill Sump Sensor(s). Model: VR 857080-111 ❑ Mechanical Line Leak Detector. Model: — ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR series 8484 ® Electronic Line Leak Detector. Model: VR series 8484 ❑ Tank Overfill\High-Level Sensor. Model: VR 790091-001 ❑ Tank Overfill\High-Level Sensor. Model: VR 790091.001 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-Diesel Tank ID 01 In-Tank Ganging Probe. Model: VR 846390.111 ❑ In-Tank Gauging Probe. Model: IN Annular Space or Vault Sensor. Model: VR 704380.301 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: VR 857080.111 ❑ Piping Sump\Trench Sensor(s). Model: N Fill Sump Sensor(s). Model: VR 857080-111 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR Series 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: VR 780091-001 ❑ 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 ® Dispenser Containment Sensor(s). Model: VR$67080-111 ® Dispenser Containment Sensor(s). Model: VR 857080.111 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID' 05-06 Dispenser ID• 07-08 ® Dispenser Containment Sensor(s). Model: VR 857D80-11 I ® Dispenser Containment Sensor(s). Model: VR 857080-111 ® 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/seryiced 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 Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the; (check all that apply): ® System set-up N Alarm history report Technician Name(print): Kris Bell Signature: Mfg.Cert.#.: B33709 ICC# 8833000 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: 8/28118