COMPLIANCE INFO_2016-2018 - Laserfiche WebLink

Home Browse Search

E E Monitoring System Equipment 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 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, §vstem control 1anel 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: 35 N. Cherokee Ln. City: Lodi, CA Zip: 95240 Facility Contact Person: manager Contact Phone No.: f209)369-1525 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 1/26/17 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specifre equipment inspected/serviced: Tank ID• 01-Regu Tank ID• 02 -Prem ❑ In - Tank Gauging Prom. Model: VR 8473so-to7 ❑ In - Tank Gauging Probe. Model: VR $47390-107 ® Annular Space or Vault Sensor. Model: VR 794390-420 ® Annular Space or Vault Sensor. Model: VR 784396-420 Piping Sump \ Trench Sensor (s). Model: VR 794380.208 ® Piping Sump \ Trench Sensor (s). Model: VR 794390-205 ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ® Mechanical Line Leak Detector. Model: RJ 116-0564 ® Mechanical Line Leak Detector. Model: Vaporiess LD2000 ❑ 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). p Other ( specify equipment type and model in Section E on Page 2). Tank ID• 03 -Diesel Tank ID• ❑ In - Tank Gauging Probe, Model: VR 947390.107 p In - Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390-420 p Annular Space or Vault Sensor. Model: ® Piping Sump \ Trench Sensor (s). Model: VR 794360.208 ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ® Mechanical Line Leak Detector. Model: Vaporless LD2000 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: p 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 I . 01-02 Dispenser ID• 03-04 ❑ 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• 05.06 Dispenser ID• 07-08 ❑ 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 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; (eheckall that apply): ® System set-up ® Alarm history report Technician Name (print): Kris Bell Signature: Mfg. Cert.#.: 833709 ICC# 5297793 -UT 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: 1/26/17