COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

R c Appendix VI JUL 17 �� MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California E i Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Co i a'�FLtL � This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepare '#of"" A T�fiEN j 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: VDP - LODI PACIFIC PRIDE Bldg.No.: Site Address: 351 N. BECKHAM ROAD city: LODI zip: 95240 Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 6/22/2018 B. Inventory of Equipment Tested/Certified Check the approgriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: RED DSL Tank Size: 8K Tank ID: 87 OCT Tank Size: 10 K ® In-Tank Gauging Probe. Model: M A G I ® In-Tank Gauging Probe. Model: M A G I ® Annular Space or vault Sensor. Model: 4 2 0 -BROKE ® Annular Space or Vault Sensor. Model: 3 4 4 ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Fill Sump Sensor(s). Model: 2 0 8 ® Fill Sump Sensor(s). Model: 2 0 8 ® Mechanical Line Leak Detector. Model: STP -MLD - D ® 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 equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 91 OCT Tank Size: 8 K Tank ID: DSL x2 Tank Size: 10& 10 ® In-Tank Gauging Probe. Model M A G 1 ® In-Tank Gauging Probe. Model: MAG I - MAG I ® Annular Space or Vault Sensor. Model: 4 2 0 ® Annular Space or vault Sensor. Model: 4 2 0 - 4 2 0 ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Piping Sump/Trench Sensor(s). Model: 2 0 8 ® Fill Sump Sensor(s). Model: 2 0 8 ® Fill Sump Sensor(s). Model: 2 0 8 VM1 -FX-IDV-T-5 ® Mechanical Line Leak Detector. Model: 99 LD 2000 ® Mechanical Line Leak Detector. Model: T-4 STP-MLD ❑ 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 - GAS &T-5 AUTO Dispenser ID: 3 / 4 - GAS & T-5 AUTO ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5 / 6 - RED DIESEL ONLY Dispenser ID: 7 / 8 - TANK 4 ONLY ® Dispenser Containment Sensogs). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9 / 10 - TANK 5 TRUCK Dispenser ID: VENT SUMP ® Dispenser Containment Sensor(s). Model: 2 0 8 ® Dispenser Containment Sensor(s). Model: 2 0 8 ® 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): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 21d STREET GALT,CA 95632 Date of Testing/Servicing: 6/22/2018 Monitoring System Certification Pagel of 4 2/21/07