COMPLIANCE INFO_2013-2018 - Laserfiche WebLink

Home Browse Search

r MONITORING SYSTEM CERTIFICATION eas� For Use By All Jurisdictions Within the State of California 6d C.C. 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. r1Gh_ 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.T The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. AUG 17 2016 A. General Information Facility Name: 24 Hrs.Gas& Mart Bldg.No:: Site Address: 1901 S. EI Dorado Street City: Stockton, CA Zip: 95206 Facility Contact Person: Sayed Contact Phone No.: (209) 207-1252 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 08/09/2016 B. Inventory of Equipment Tested/Certified Check the ageropriate boxes to indicates ecific a ui ment inspected/serviced: Tank ID: #1 Regular 87-9000 Gal, Tank ID: #2 Premium 81 -3000 Gal ®In-Tank Gauging Probe. Model: MAG-1 ®In-Tank Gauging Probe. Model: MAG-1 ®Annular Space or Vault Sensor. Model: 794380.420 ®Annular Space or Vault Sensor. Model: 794380.420 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ®Piping Sump/Trench Sensor(s). Model: 794380-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: Vaporless 99LD2000 ®Mechanical Line Leak Detector. Model: Vaporless 99LD2000 ❑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: 3-4 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®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). 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): Nik Zagorov Signature: 1y gelR r'"' ov Certification No.: Veeder Root Level 4#A32784 License.No.: 958763 Testing Company Name: ECO-CHEK Compliance, Inc. Phone No.: (888) 500-CHEK Testing Company Address: P.O. Box 1394, Lafayette, CA 94549 Date of Testing/Servicing: 08/09/2016 Page 1 of 4 Rev(2/08)