COMPLIANCE INFO_1998-2008 - Laserfiche WebLink

Home Browse Search

NIT NG SYSTEM CETIFI ION 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 I 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: SBC Site Address: 907 LINCOLN ROAD GEO PAR # UE -046 City: CLLC Code: SKTNCAI i STOCKTON Zip: Facility Contact Person: KATHY HALLIGAN Contact Phone No.: 209474-4514 Make/Model of Monitoring System: VEEDER ROOT TLS -350 Date of Testing/Service: 8/6/04 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 1171 Tank ID: ®In -Tank Gauging Probe: Model: 847390-106 ❑In -Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390-420 []Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor (s): Model: 794380-352 ❑Piping Sump/Trench Sensor (s): Model: ®Fill Sump Sensor (s): Model: 794380-352 []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: 790091-001 ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify e juip. type and model in Section E on Page 2 ❑Other, S ecif equip. a and model in Section E on Page 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, S ecify e ui a and model in Section E ojELSe 2 ❑Other, S ecify e uip. a and model in Section E on Page 2 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 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) ❑Dis enser 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) ❑Dis enser 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. Certitication - 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-up ® Alarm history report V2 Technician Name (Print): BRIAN GONZALES Signature: ^' Certification No.: 4812 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222