COMPLIANCE INFO_2009-2018 - Laserfiche WebLink

Home Browse Search

Appendix VI lo (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at nttpJ/www.waterboards.caq.gov .) MONITORING SYSTEM CERTIFICATION FE 1 1 For Use By All Jurisdictions Within the State of California Authority Cited.Chapter 6.7,Health andSafety Code;Chapter 16,Division 3, Title 23,California Code ofRe091RMMENTALHE&TH This form must be used to document testing and servicing of monitoring equipment.A separate certification or report m8ER"r I4 -Wh 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 o fthis form to the local agency regulating UST sy stems within 30 days of test date. A. General Information Facility Name: Pacific Bell Telephone Co dba ATT California Facility ID: UE046 Site Address: 907 Lincoln Rd. City: Stockton Zip: 95207 Facility Contact Person: Thuy Tran Contact Phone No.: (209)532-3447 Make/Model of Monitoring System: Veeder Root TLS-350 Plus Date of Testing/Servicing: 2/3/2017 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment i nsp ected/serviced: Tank ID: UE0460002 Tank ID: N In-Tank Gauging Probe. Model: 846390-104/716086 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794390-420/195625 ❑Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 794380-208/674465 ❑Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-208/685055 ❑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: 0 Tank Overfill/High-Level Sensor. Model: Non Veeder Root F-1TankOverfill/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: ❑ 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 type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑ Shear Valve(,). ❑ 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). Mode 1: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑Dispenser 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. 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 correctand 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 Q Alarm history report Technician Name(print): Garrett Warren (/(/wtwa Signature: Certification No.: 842126 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 SOUTHDUPONT ERIVE,ANAHEIKCAmsoe Date of Testing/Servicing: 2/3/2017