COMPLIANCE INFO_2005-2018 - Laserfiche WebLink

Home Browse Search

Feb. 6. 2012 8:33AM RUM CONSTRUCTION No, 1140 P. 2/6 NI N SYSTEM CE TI IION For Use By All Jurisdictions 97th in the State of California Authopiry Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, 71tde 23, California Code ofAdgulations This form must be used to document testing and servicing of monitoring equipment. A se crate certification or report must r each monitoring system control panel by the technician who performs the work. A copy of this farm must be provided to the tank cystt�+p The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. t A. General Information Facility Name: STOCKTON CHP Bldg. No.: Site Address: 3330 N. AD ART RD. City: STOCKTON Zip: 95215 Facility Contact person: JIM MURRAY Make/Model of Monitoring System: V/R TLS 350 B. Inventory of Equipment Tested/Certified Contact Phone No.: (2209) 943-8666 Date of Testing/Servicing: 1/30/2012 Tank ID: 87 ® In -Tank Gauging Probe. Model: V/R Annular Space or Vault Sensor. Model; V/R 420 ® Piping Sump / Trench Sensor(s). Model; V/R 208 ® Fill Sump Sensor(s). Model: V/R 208 ® Mechanical Line Leak Detector, Model; FE PETRO ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / High-'Levcl Sensor, Model: FLAPPER ❑ Other (specify equipment type and model in Section E on Page 2). Tank 1D: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s), Model; ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: ❑ Electronic Line Loak Detector, Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Tank 10D: T'ank 1D: ❑ 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 Seer, Model: ❑ Tank Overfill / High -Level Sensor. Model; _ ❑ Other (specify equipment type and model in Section B on Pago 2), ❑ Other (specify equipment we and model in Section E on Page 2). Dispenser ID: 112; Dispenser 11D: ® Dispenser Containment Sonsor(s), Model: V/R 208 ❑ DispenserContainmcnt Senmr(s). Model: ® Shear Valvo(s). ❑ Shcar Valvc(s), ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 11): Dispenser ID: ❑ Dispenser Containment Sensor(s)• Model: ❑ Dispenser Containment Sensor(%). Model: ❑ Shear Valve(s). ❑ Shear Valvc(s), ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser 111): Dispenser 1D: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shur V'alve(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 correct and a Plot Platy showing the layout of monitoring equipment. For any equipment capable of generati reports, I have also attached a copy of the report; (check all that apply): System set-up ® Alarm hl rt. - Technician Name (print), Phillip Mendrin Signature: Certification No.: 5252185 -UT License, No,•� 72234 14-1 Testing Company Name: Ramex Construction Corp Phone No.: (559) 271-3300 Testing Company Address: 4670 N. Bendel Ave. Fresno CA 93722 Date of Testing/Servicing: 1/30/2012 Page 1 of 3 Rev (2/08)