Laserfiche WebLink
0 — , __ "_', "__ "_, -, 11� <br />MONITORING SYSTEM CERTIFICATION--', <br />MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-3P,i ( i <br />CERTIFICATION /TEST DATE: Auaust 09. 2017 <br />Al. FACILITY A2. OWNER,�i <br />Name Quik Stop Market #138 Name Quik Stop rice s,` Inc <br />Address 1153 Lincoln Blvd., Tracy, CA 95376 Address 4567 Enterprise Street; Fremont; CA 94538 <br />Phone # 510-657-8500 Phone # 510-657-8500 <br />Contact Roger Batra Contact Debbie Markovich <br />A3. C U P A <br />Tank #2 (Product): 89 Gasoline <br />A4. TESTING CONTRACTOR <br />Name <br />San Joaquin County Environmental Health <br />Model: <br />Name <br />Walton Engineering, Inc. <br />Address <br />1868 E. Hazelton Avenue, Stockton, CA 95202 <br />Annular Space or Vault Sensor <br />Address <br />P.O. Box 1025, W. Sacramento, CA 95691 <br />Notified <br />July 25, 2017 <br />Lic # <br />617238 A, B, Haz <br />Inspector <br />Cesar Ruvalcaba <br />Model: 0794380-208 <br />Contact <br />Veronica Freitas <br />Phone # <br />209-468-3442 <br />Fill Sump Sensor(s) <br />Phone # <br />916-373-1166 <br />B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) <br />Model: VMI 99LD-2000 <br />B1: <br />TANKS <br />Model: VMI 99LD-2000 <br />Tank #1 (Product): 87 Gasoline <br />Tank #2 (Product): 89 Gasoline <br />❑ <br />In -Tank Gauging Probe <br />Model: <br />❑ <br />In -Tank Gauging Probe <br />Model: <br />Annular Space or Vault Sensor <br />Model: 0794390-409 <br />Shear Valves <br />Annular Space or Vault Sensor <br />Model: 0794390.409 <br />Piping Sump / Trench Sensor(s) <br />Model: 0794380-208 <br />Piping Sump / Trench Sensor(s) <br />Model: 0794380-208 <br />❑ <br />Fill Sump Sensor(s) <br />Model: <br />❑ <br />Fill Sump Sensor(s) <br />Model: <br />❑ <br />Mechanical Line Leak Detector <br />Model: VMI 99LD-2000 <br />Shear Valves <br />Mechanical Line Leak Detector <br />Model: VMI 99LD-2000 <br />❑ <br />Electronic Line Leak Detector <br />Model: <br />❑ <br />Electronic Line Leak Detector <br />Model: <br />❑ <br />Tank Overfill / High -Level Sensor <br />Model: <br />❑ <br />Tank Overfill / High -Level Sensor <br />Model: <br />❑ <br />Other (specify equipment in Section E) <br />Model <br />❑ <br />Other (specify equipment in Section E) <br />Model: <br />❑ <br />Dispenser Containment Float(s) and Chain(s) <br />Tank #3 (Product): 91 Gasoline <br />Tank #4 (Product): _ <br />❑ <br />In -Tank Gauging Probe <br />Model: <br />❑ <br />In -Tank Gauging Probe <br />Model: <br />Annular Space or Vault Sensor <br />Model: 0794390-409 <br />❑ <br />Annular Space or Vault Sensor <br />Model: <br />Piping Sump / Trench Sensor(s) <br />Model: 0794380-208 <br />❑ <br />Piping Sump / Trench Sensor(s) <br />Model: <br />❑ <br />Fill Sump Sensor(s) <br />Model: <br />❑ <br />Fill Sump Sensor(s) <br />Model: <br />Mechanical Line Leak Detector <br />Model: VMI 99LD-2000 <br />❑ <br />Mechanical Line Leak Detector <br />Model: <br />❑ <br />Electronic Line Leak Detector <br />Model: <br />❑ <br />Electronic Line Leak Detector <br />Model: <br />❑ <br />Tank Overfill / High -Level Sensor <br />Model: <br />❑ <br />Tank Overfill / High -Level Sensor <br />Model: <br />❑ <br />Other (specify equipment in Section E) <br />Model: <br />❑ <br />Other (specify equipment in Section E) <br />Model: <br />C. CERTIFICATION I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. <br />Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing th <br />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 <br />■ Svstem set-uD 0 Alarm History Report <br />ACTON <br />Signature: A tttN»IN. tNC. <br />Technician / Cert #: Scott Beall / B46116 8319310 Date: August 9, 2017 <br />Dispenser #: 1-2 <br />Dispenser # : 3-4 <br />❑ <br />Dispenser Containment Sensor(s) Model: <br />❑ <br />Dispenser Containment Sensor(s) Model: <br />Shear Valves <br />Shear Valves <br />Dispenser Containment Float(s) and Chain(s) <br />Dispenser Containment Float(s) and Chain(s) <br />Dispenser # : <br />Dispenser # : <br />❑ <br />Dispenser Containment Sensor(s) Model: <br />❑ <br />Dispenser Containment Sensor(s) Model: <br />❑ <br />Shear Valves <br />❑ <br />Shear Valves <br />❑ <br />Dispenser Containment Float(s) and Chain(s) <br />❑ <br />Dispenser Containment Float(s) and Chain(s) <br />Dispenser # : <br />Dispenser # : <br />❑ <br />Dispenser Containment Sensor(s) Model: <br />❑ <br />Dispenser Containment Sensor(s) Model: <br />❑ <br />Shear Valves <br />❑ <br />Shear Valves <br />❑ <br />Dispenser Containment Float(s) and Chain(s) <br />❑ <br />Dispenser Containment Float(s) and Chain(s) <br />C. CERTIFICATION I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. <br />Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing th <br />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 <br />■ Svstem set-uD 0 Alarm History Report <br />ACTON <br />Signature: A tttN»IN. tNC. <br />Technician / Cert #: Scott Beall / B46116 8319310 Date: August 9, 2017 <br />