COMPLIANCE INFO_2014-2017 - Laserfiche WebLink

Home Browse Search

9255517888 Line 1 im GfrrLEe-RYAN INc. 09:54:58 01-02-2014 2/10 ab # 20-592715 Appendix VI RECEIVED MONITORING TIFiTI For Use By All Jurisdictions Within the State of Cat#orrlia A , Q � Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 96, Division 3, Title 23, Califo a o 0 Regulations ENVIRONMENTAL This form must be used to document testing and servicing of monitoring equipment. A separate certification or report W"bWQ6B4WMENT 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: Arco 5450 Bldg. No.: Site Address: 1617 W Fremont City. Stockton zip: Facility Contact Person: Contact Phone No.: MakefModal of Monitoring System: TLS350R Date of Testing/Servicing: 12/23/2013 B. Inventory of Equipment Tested/Certified is use lacmty cusuams more canrcs or aispensers, copy inis Torm. inauee rmormation Tor 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 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 Technician Name (print): Elodlo Sanchez Signature: .- Certification No.: B41204 License. No.: 220793 Testing Company Name: GetiBer-Ryan Inc. Phone No.: 925-551.7555 Testing Company address: 6747 Sierra Court Suite J, Dublin, Ca. 94568 Date of restikatservicing: 12/23/2043 Monitoring System Certification Page 1 of 4 92/07 1 l.uo4R um ajjpFvPrlas= uuxes w maicate s eras equipment ma ecrearservicea: Tank ID: 87-1 Tank 10- 87.2 ❑ in -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: IM Piping Sump / Trench Sensor(s). Model: 794-380-208 ® Piping Sump/ Trench Sensor(s). Model: 794380-20 ❑ Fill Sump Sensor(s). Model: ❑ FIR 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 1 High -Level Sensor. Model: ❑ Other (sim& equipment and model In Section E on Pa e 2 . ❑ Other ec equipment type and model In Section TankiD: 91 TanklD: ❑ In -Tank Gauging Proba. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ® Piping Sump/ Trench Sensor(s). Model: 794W-208 ❑ 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 Lane Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. el: ❑ Other (soVA 29ulpment type and model in Section E on Pa e 2). ❑ Other (specify ui ment tvpe and model in Section E an 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 Fioa s and Chains . ❑ Dis user Containment Floa a and Chain(s). DispenserlD: Dispenser ID: ❑ Dispenser Containment Sensor(s). Madel: ❑ Dispenser Containment Sensoria). Model: ❑ ShearValve(s). ❑ ShearVahre(s). ❑ Dis enser Containment Floes and Chains . ❑ Dispenser Containment F s and Chains . DispenserlD: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Di2eenser Containment Flo s and Chain(s). ❑ Disgoser Containment Fina s and Chai s . is use lacmty cusuams more canrcs or aispensers, copy inis Torm. inauee rmormation Tor 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 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 Technician Name (print): Elodlo Sanchez Signature: .- Certification No.: B41204 License. No.: 220793 Testing Company Name: GetiBer-Ryan Inc. Phone No.: 925-551.7555 Testing Company address: 6747 Sierra Court Suite J, Dublin, Ca. 94568 Date of restikatservicing: 12/23/2043 Monitoring System Certification Page 1 of 4 92/07 1