Laserfiche WebLink
Jan.23. 2015 12:33PM RUMEX CONSTRUCTION N0.9 <br />M0410PJNG SYM <br />STEM CERT*T-01, N�dEIVED <br />For Use By All Jurisdictions Vithin the State of California <br />Authority 3 ntle 3,California ode Re#A+#qs <br />Cited: Chapter 6 7 Health and Safety Code; Chapter 16, Division , 2 C Of 3 2015 <br />This form must be used to document testing and servicing of monitoring equipment. A gMarate certification or Lep—ort " he0jWW ior"11 <br />monitoring systorn control parcel by the technician who performs the work. A copy of this form must be provided to thetallIWAWWWW, IAL <br />The owner/operator must submit acopy of this form to the local ageneyregulating UST systems vAtbin 30 days of tat date, 14cWTL4r)PPAPTM!:NT <br />A. General Information <br />Facility Name: CHP Stockton <br />Bldg. No.: <br />Site Address: 3330 North Ad Art Road <br />City. Stockton Zip: 95215 <br />Facility Contact Person: Sergeant Bartlett <br />Contact Phone No.: (209) 481-5989 <br />Make/Model of Monitoring System: TLS 360 <br />Date of Testing/Servicing: 112012016 <br />8. Inventory of Equipment Teste&Certified <br />Check the miroorlaft boxes to Indicate M!clfic 19aigmeat ins <br />serwleed: <br />Tank ID: 87 <br />Tank ID - <br />0 hi -Tank Gauging Probe. Model; VR <br />rl In -Tank Gauging Probe, Model: <br />0 Amular Spice or Vault Sensor. Model: VR 309 <br />El Annular Space or Vault Sensor, Model: <br />0 Piping Sump / Trench Sensor(s). Model: VR 208 <br />0 Piping Sump / Trench Sensor(t). Model: <br />0 Fin Sump Sensox(g). MOM: VR 208 <br />0 Fill Sump Sensor(s). Model: <br />0 Mechanical Line Leak Detector. Model: FE PETRO <br />Mechanical Line Leak Detector. Model: <br />0 Electronic line Leak Detector. Model: NA <br />Electronic Lice Leak Detector. Model: <br />0 Tank Overfill / High -Level Sensor. Metal: FLAPPER <br />0 Tank Overfill / High -Level Sensor. Model: <br />0 Other (specify equipment type and model in Section E on Page 2). <br />0 Other (specify equipment type and model in Section R an Page 2). <br />Tank ID; <br />Tank ID: <br />0 in -Tank Ganging Probe. Model., <br />0 in -Tank Gauging Probe. Model: <br />0 Annular Space or Vault Sensor. Model, <br />0 Annular Space or Vault Sensor. Model; <br />[I Piping Sump /Trench Sensor(s). Model, <br />n Piping Sump / Trench Sensor(s). Model! <br />0 Fill Sump Sensor(s). Model, <br />n Fill Sump Sensor(s). Model, <br />0 Mechanical Line LAA Detector. Mode -1; <br />0 Mechanical Line Leek Detector. Modcl, <br />0 Electronic Lino Leak Detector. Model: <br />0 Electronic I= Leak Detector, Model, <br />0 Tank Overfill / Sgh-Level Sensor, Modd- <br />0 Tank Overfill / high -Loved Sensor. Model, <br />0 Other (specify equipmeM type and model in Section E on Page 2). <br />0 Other (specify equipment type and model in Section E on Page 2). <br />Dispenser 1D.- 1/2 <br />Dispenser ID: <br />0 Dispenser Containment Sensor(s). Model; VR 208 <br />0 Dispenser Containment Somr(s), Model; <br />0 Shear Valve(s). <br />0 Shear Valve(s). <br />0 Dispenser Containment Floats) and Chain(s). <br />[I Dispenser Containment Float(s) and Chain(s). <br />Dispenser 1D., <br />Dispenser ID: <br />Q Dispenser Containment Samr(s), Model; <br />0 Dispenser Containment Senscr(s). Model: <br />0 Shear Valve(s). <br />0 Shear Valve($), <br />E] Dispenser Contaimnent Float(s) and Chain(s). <br />[I Dispenser Containment Float(s) and Chain(&). <br />Dispenser ID: <br />Dlfipeuscrw <br />E) Dispenser Containment Saisor(s), Model-, <br />El Dispenser Containment Samr(s), Model: <br />0 Shear Valve(s), <br />0 Shear'Valve(s), <br />[I Dispenser Containment Float(s) and Chait(s). <br />0 Dispenser Containment Float(s) and Chin(s). <br />*If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility, <br />C. Certification - I certify that tho equipmetit Identified <br />in this document was inspected/serviced in accordance with the manufacturers' <br />guidelines. Attached to this Certification Is information (e.g. manufacturers' checklists) necessary to verity that this information Is <br />correct and a Plot Plan showing the layout of monitoring equipment. For any eq able of generating such reports, I have also <br />attached a copy of the report; (check aU that apply): <br />Z System set-up 0 Alarm histo <br />Technician Name (print): KyleSechdoldt <br />Signature: <br />Certification No.: SM783 <br />License. No.. 872234 <br />Testing Company Name., Rumex Construction Corp <br />Phone No.: 559 271-3300 <br />Testing Company Address, 3755 W. GettYsburg Ave., Fresno, IZA_ 93722 Date of TestireServicing: 1 12DI J15 <br />Page I of 3 <br />Rev (2/08) <br />