COMPLIANCE INFO_2013-2018 - Laserfiche WebLink

Home Browse Search

D U"I L 0 JUN 08 2-0118 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cite&Chapter 6.7,Health and Safety Code, Chapter 16,Division 3, Title 23, Californii�C,04e-of,,Regudoem—tc.NT This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be pEgmcd-for monitoring UgLm control 2gnel 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: UPS Bldg.No.: Site Address: 1.632 North Broadway City: Stockton Zip; 95206 Facility Contact Person: Ramona Powell Contact Phone No.: (916) 373-6874 Make/Model of Monitoring System, Veader RooUTLS 350 Date of Testing/Servicing: 512312018 B. Inventory of Equipment Tested/Certified Check the!Wopriate boxes to indicate specific equipment ins pmted 1serviced: Tank ID: T-1 Diesel Took ID: 0 In-Tank Gauging Probe, Model: Mag-1 El In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 302 El Annular Space or Vault Sensor. Model: Piping Sump/Trench Scrisor(s). Model: 208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Scrisor(g). Model: ❑Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 99LD2000 ❑Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model-. C1 Electronic Line Leak Detector. Model: Tank Overfill I High-Levcl Sensor, Model: ORPWW611so El 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: Tank ID: [I In-Tank Gauging Probe Model: [I In-Tank Gauging Probe. Model: [3 Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump I Trench Sensor(s). Model: 0 Piping Sump/Trench Scrisor(s). Model: 0 Fill Sump Scn&*s)_ Model: ❑Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector_ Model: ❑Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Pap 2). ED Other(specify equipment roe and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 330212-M El Dispenser Containment Sensor(s), Model: Shear valve(s). 0 Shear valve(s). ❑Dispenser Containment Float(s)and Chain(s). [I Dispenser Containment Flost(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sensor(s). Model: Shear Valve(s). 0 Shear Vatvc(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). [I Shear Valve(s). D Dispenser Containment Float(s)and Chain(s). -A C1 Dispenser Containment Homo)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 manubdurers' 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 Ala report Technician Name(print): David Pereira Signature: Certification No.: 62318 License.No.: 416807,62407394)T,A28961 Testing Company Name: R.L Stevens Co. Phone No.:(510) 889-0908 Testing Company Address: 22254 Meekland Ave.Han2rd,Ca 94541 Date of Testing/Servicing: 612312018 Page I of 3 Rev(2/08)