COMPLIANCE INFO_2011-2018 - Laserfiche WebLink

Home Browse Search

W .. CEIVED 12 2011 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan availab i t R s.ca. ov.) MONITORING SYSTEM CERTIFICATidVIT/SERVICES 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 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 ownerloperator. The ownerloperator 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: Waterloo Liquors Bldg. No.: Site Address: 2512 E. Waterloo City: Stockton Zip: 95205 Facility Contact Person: Heng Contact Phone No.: ( 209 ) 607-5022 MakelModel of Monitoring System: Incon EMS Date of TestinglServicing: 06 129 12010 B. Inventory of Equipment TestedlCertified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: # - 87 Regular Tank ID13 - Diesel E In -Tank Gauging Probe. Model: E In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 420 X Annular Space or Vault Sensor. Model: 420 X Piping Sump I Trench Sensor(s). Model: 208 X Piping Sump I Trench Sensor(s). Model: 208 E Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FE Petro X Mechanical Line Leak Detector. Model: FE Petro E Electronic Line Leak Detector. Model: E Electronic Line Leak Detector. Model: X Tank Overfill I High -Level Sensor. Model: flap X Tank Overfill I High -Level Sensor. Model: flap E Other (specify equipment type and model in Section E on Page 2). E Other (specify equipment type and model in Section E on Page 2). Tank ID: #2 - 91 Premium Tank ID: E In -Tank Gauging Probe. Model: E In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 420 E Annular Space or Vault Sensor. Model: X Piping Sump I Trench Sensor(s). Model: 208 E Piping Sump I Trench Sensor(s). Model: E Fill Sump Sensor(s). Model: E Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FE Petro E Mechanical Line Leak Detector. Model: E Electronic Line Leak Detector. Model: E Electronic Line Leak Detector. Model: X Tank Overfill I High -Level Sensor. Model: flap E Tank Overfill I High -Level Sensor. Model: E Other (specify equipment type and model in Section E on Page 2). E Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 -2 Dispenser ID: X Dispenser Containment Sensor(s). Model: 420 E Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s), E Dispenser Containment Float(s) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: X Dispenser Containment Sensor(s). Model: 420 E Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). E Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: E Dispenser Containment Sensor(s). Model: E Dispenser Containment Sensor(s). Model: E Shear Valve(s). E Shear Valve(s). E Dispenser Containment Float(s) and Chain(s E 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 - 1 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, 1 have also attached a copy of the report; (check all that apply): E System set-up Alarm history report Technician Name (print): Stephen Zwahlen Signature: t Certification No.: 4341047029 License. No.: Testing Company Name: Franzen Hill Phone No.:(559 ) 688-2977 Testing Company Address: 1100 NJ STREET TULARE CA93274 Date of TestinglServicing: 6 129 1 10 Monitoring System Certification Page 1 of 4 12/07