COMPLIANCE INFO_2012-2017 - Laserfiche WebLink

Home Browse Search

n • RECEIVED 140714-197 �, Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httD: ' . EALTH MONITORING SYSTEM CERTIFICATION DEPARTMENT For Use By Alt Judsdktions 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 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: Manteca CO Bldg. No.: CA478441.9 Site Address: 430 W. Center Street City: Manteca Zip: 95336 Facility Contact Person: Masood. Choudhurry Contact Phase No.: 909-613-1553 Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Te glServiang: 8/28/ 14 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate edfic ul ment in ected/serviced: Tank ID: TG013935-DIESEL-6 000 GAL. Tank ID- R In -Tank Gauging Probe. Model: 847390-107 a In -Tank Gauging Probe. Model: B Annular Space or Vault Sensor. Model: 794380-320 0 Annular Space or Vault Seng. Model: IE Piping Sump / Trench Sensor(s). Model: 794380-350 a Piping Sump / Trench Sensor(s). Model- [; Fill Sump Sensor(s). Model: 794380-350 13 Fill Sump Sensor(s). Model: t3 Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: D Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 19 Tank Overfill / High -Level Sensor, Model: 790091-001 13 Tank Overfill / High -Level Sensor. Model: R Other (specify 2quipment type and model in Section E on Pa 2). 0 Other LsE2a equiEMent a and model in Section E on PM 2). Tank ID: Tank ID: 13 In -Tank Gauging Probe. Model: a In -Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Seng. Model: ® Piping Sump / Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: 13 Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: a Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: o Electronic Line Leak Detector. Model: 13 Tank Overfill / High -Level Sensor. Model: a Tank overfill / Hlgh► Level Seng. Model: Q Other (specify IguieMent p2e and model in Section E on Pa 2). 0 Others ui eM a and model in Section E on =J2. Dispenser ID: Dispenser ID: O Dispenser Containment Sensor(s). Model: C Dispenser Containment Sensor(s). Model: ® Shear Valve(s). 0 Shear Valve(s). D Dispenser Containment Float(pj and Chain(s). A Di neer Containment Floats and Chain(s). Dispenser ID: Dispenser ID: Q Dispenser Containment Sensor(s). Model: a Disperser Containment Sensor(s). Model: • Shear Valve(s). O Shear Valve(s). O Dispenser Containment Floats and Chains . 13 Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: a Disperser Containment Sensor(s). Model: 17 Disperser Containment Sensor(s). Model: 13 Shear Valve(s). O Shear Valve(s). D Disperser Containment Float(s) and Chains C Dispenser Containment Floats and Chain(s). "fi 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 verity that this Information Is correct and a Piot 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 at/ that r): system set-up o Alarm history reAn por Dg� ljf ne {�y Leona* 9AarVVff#1�O7W97 Technician Name (print): Leonardo Aguilar Signature: (1�28i U 122 6 Certification No.: 5302718 -UT License. Na: 703190 Testing Company Name: SUN W EST ENGINEERING Phone Na: 8f 88 ) 588-8737 Testing Company Address.. 4780 CHEYYENE WAY CHINO CA.91710 Date of TestinglServicing: 8/28/14 Monitoring System Certification Page 1 of 4 12107 Document Reviewed 8/29/201410:50 AMJustin Trelstad QA/QC APPROVED 1 2/21/07 9/5/20145:13 PMMike P. B