COMPLIANCE INFO_2002-2015 - Laserfiche WebLink

Home Browse Search

Appendix VI MONITORING SYSTEM CERTIFICATION 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 o 411ALZo 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 KNIFE RIVER DSS Bldg. No.: - ,. -Alamo Site Address: 655 WEST. CLAY STREET City: STOCKTON Zip: - Facility Contact Person JOHN Contact Phone No.: (209) 948-0302 Make/Model of Monitoring System: VEEDER ROOT TLS 300 Date of Testing/Servicing: 7127/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment Insected/serviced: Tank ID: 87 Tank ID: DIE ® In -Tank Gauging Probe. Model: MAG 1 ® In -Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 407 ® Annular Space or Vault Sensor. Model: 407 • Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD 2000 ® 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 type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page -2). TanklD: TanklD: ❑ 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 Pagrg), Dispenser ID: 1.2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 20 a o ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). _ DispenserlD: 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). Cl Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model' 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. .+_� a__"__ • __...c. __ -e__'__. u__.:e_.� :_ .ate.....__.....__ :___�_.L�__...u..a e. ................... ...u�, aa... ........ s.,.........bi ... .. ..... guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct ends Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also att :aka copy of the report; (check all that apply): 0 System set-up ® Alarm history report Technician, Name print): FELIX RAMIREZ Signature;- Certification No.: B34976 License No: 5273934 -UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2 STREET GALT, CA 95632 Date of Testing/Servicing: 07-27-12 Monitoring System Certification. Page 1 of 4 2/21/07