COMPLIANCE INFO_2006-2015 - Laserfiche WebLink

Home Browse Search

MONI RING SYSTEM CETIF ATION ' 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 This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be pre ap red 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 mus ggrm to the local agency regulating UST systems within 30 days of test date. CL UU A. General Information API�P Facility Name: City of Stockton o 1000 Bldg. No.: Corp Yard Site Address: 1465 S. Lincoln StreetCity: Stockton Zip 95206 Facility Contact Person: Phil Burnside ENVIRONMEN 1 HEALWritact Phone No.: (209) 937-7417 Make/Model of Monitoring System: EBW AUTCf-kTIkTd1ZERVICES Date of Testing/Servicing: March 08, 2006 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspect Tank ID: #1 DIESEL FUEL Tank ID: Tank ID: [x] In -Tank Gauging Probe. Model: 7100EBW 108120 (x)In-Tank Gauging Probe. Model: 7100EBW 108120 ❑ In -Tank Gauging Probe. Model: (x)Annular Space or Vault Sensor. Model: LS -30A ❑ Annular Space or Vault Sensor. Model: (x)Piping Sump / Trench Sensor(s). Model: LS -30A ❑ 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 (snecifv eauinment tvoe and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: #2 UNLEADED GASOLINE Tank ID: ❑ In -Tank Gauging Probe. Model: [x] In -Tank Gauging Probe. Model: 7100EBW 108120 [x]Annular Space or Vault Sensor. Model: LS30-A ❑ Annular Space or Vault Sensor. Model: [x] Piping Sump / Trench Sensor(s). Model: LS30-A ❑ 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 t e and model in Section E on Pae 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 7/8 [x] Dispenser Containment Sensor(s). Model: Beaudreau Model 406 IM Dispenser Containment Sensor(s). Model: Beaudreau Model 406 ® Shear Valve(s). ® Shear Valve(s). ( )Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float s) and Chain(s). Dispenser ID: 3/4 Dispenser ID: M Dispenser Containment Sensor(s). Model: Beaudreau Model 406 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: ® Dispenser Containment Sensor(s). Model: Beaudreau Model 406 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Fioat(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 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 (X) Alarm history report Technician Name (print): ERIC MOLGAARD Signature.: Eric MoCgaard Certification No.: ICC 5250200 -UT EBW 04125149E License No.: 309105 Testing Company Name: Stockton Service Station Equipment Co., Inc. Phone No 209-464-8333 Site Address: 1465 S. Lincoln Street, Stockton, CA 95206 Date of Testing/Servicing: March 08, 2006