COMPLIANCE INFO_2017-2018 - Laserfiche WebLink

Home Browse Search

RECEIVED JUN 1 5 2018 Appendix V1 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.g MONITORING SYSTEM CERTIFICATION For Use By Aff Jurisdictions Within the State of California Authority Cited. Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Tide 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 prepared 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 must submit a copy of this form to the local agency regulating LIST systems within 30 days of test date. A. General Information Facility Name: _Grupe Airport Bldg.No.: Site Address:5000 S Lindbergh St_ City.Stockton Zip:95206_ Facility Contact Person:Maurice Contact Phone No.:(209)473-6204 Make/Model of Monitoring System:Veeder-Root TLS 300C Date of Testing/Servicing:611412018 B. Inventory of Equipment Tested/Cerfified Check the aeeroeriate boxes to Indicate smific asul went insecteNserviced: Tank ID:Jet A Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model:409 ❑ Annular Space or Vault Sensor. Model: Li Piping Sump/Trench Sensor(s). Model:208 ❑ Piping Sump/Trench Sensor(s). Model; X Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model• ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model- El Electronic Line Leak Detector. Model: Li Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill I High-Level Sensor. Model• ❑ Other(specify equieMent D=and model In Section E on P 2). ❑ Other(specify!2ulETent Do and model In Section E on Page 2). Yank ID: Tank ID: 0 In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump I Trench Sens*q3). Model: 0 Piping Sump I Trench Sensor{s). Model: n Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: n Mechanical Line Leak Detector. Model: n Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: n Electronic Line Leak Detector. Model: n Tank Overfill/High-Level Sensor. Model: n Tank Overfill/High-Level Sensor. Model: n Other ulgerd type and model in Section E on Page 2), n Other(specify equipment type and model in Section E on P 2). Dispenser ID: DispenserID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model• () Shear Valve(s)-(DPW) n Shear Valve(s). ❑ DINnM Containment sand ChaI2(s n DlsContainment f2gatjs arkl Cha!!gs). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: n Dispenser Containment Sensor(s). Model• () Shear Valve(s). (DPW) ❑ Shear Valve(s). ❑ Dispenser Containment D22tjsj and ChaiEgs). ❑ gyenser Containment Floats and Chainfs). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: () Shear Vak*s). (DPW) ❑ Shear Valve(s). ❑ Disanser Containment Flog(s)and Chains ❑ Disg2gser Containment Float 0 and Chaln(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): ❑syste"-up ❑AI history report Technician Name(print):Chris Adams Signature: Certification No.:B43531 License.No. 31 A-HAZ Testing Company Name:ELITE IV CONTRACTORS Phone No.:L209_)_461-6337 Testing Company Address:2535 Wigwam Dr Stockton Ca 95205 Date of Testing/Servicing:6/14/2018 Monitoring System Certification Page I of 4 12107 2/21/07