COMPLIANCE INFO_2003-2005 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM 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 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: Quik Stop Market#121 Bldg.No.: Site Address: 1196 W. Louise Ave. City: Manteca Zip: 95336 Facility Contact Person: Michael Karyelot Contact Phone No.: 510 )657-8500 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 5 /23 /05 B. Inventory of Equipment Tested/Certified Check the appro Hate boxes to indicates ecitic a ui ment inspected/serviced: Tank ID: 87 Tank ID: 91 In-Tank Gauging Probe. Model: Hoag Probe 0 In-Tank Gauging Probe. Model: Mag Probe Annular Space or Vault Sensor. Model: PA002593000002 0 Annular Space or Vault Sensor. Model: PA002593000002 ■ Piping Sump/Trench Sensor(s). Model: PA002592000010 N Piping Sump/Trench Sensor(s). Model: PA002592000010 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: FE Petro STP-MLD 0 Mechanical Line Leak Detector. Model: FE Petro 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 a and model in Section Eon Page 2). ❑Other(s2ecify a ui ment type and model in Section E on P e 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 a and model in Section E on P2ge 2). ❑Other(specify equipment a and model in Section E on P e 2). Dispenser ID: 1-2 Dispenser ID: 3-4 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). 0 Shear Valve(s). Dispenser Containment Floats and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5-6 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). ❑Dis enser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats 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-upm history report Technician Name(print): Phillip Klingman Signature:?__ Certification No.: 006-05-0809 License.No.: 617238 Testing Company Name: Walton Engineering,Inc. Phone No.:( 916 ) 373-1152 Site Address: 3900 Commerce Drive,West Sacramento,CA 95691 Date of Testing/Servicing: 5 / 23 / 05 UN-036-1/4 Page 1 of 3 Rev.06/04/01 CUPA: San Joaquin County Enviro Health WALTON INSPECTOR: Ray Von Flue ENGINEERING, INC. www.unidoes.org