COMPLIANCE INFO_2013-2018 - Laserfiche WebLink

Home Browse Search

T 0 *RECEIVE[ MONITORING SYSTEM CERTIFICAT 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 T' iM 6 This form must be used to document testing and servicing of monitoring equipment. A name certification or report must be pz=md for cad monitoring @=in control panel by the technician who performs the work. A copy of this form must be provid The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days rLl'F," A. General Information DEPARTMENi Facility Name: Arco Bldg. No.: Site Address: 2430 Joe Pombo Pwy City: Tracy, Ca. Zip: 95376 Facility Contact Person: Ranjeet Contact Phone No.: (209) 679-4014 Make/Model of Monitoring System: Vender Root TLS -350 Date of Testing/Servicing: 10/19/2016 B. Inventory of Equipment Tested/Certified rAnnular nate boles to indicates tic a ai meat Inspec 87 Master Tank ID: T2: 87 Siphon ing Probe. Model: 847390-109 In -Tank Gauging Probe. Model: 847390-109 or Vault Sensor. Model: 794390.409 ® Annular Space or Vault Sensor. Model: 794390-409(split tank) / Trench Sensor(s). Model: 794380-323 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 0-323 ® Fill Sump Sensor(s). Model: 794380423 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Lire Leak Detector. Model: 8484 ❑ Electronic Lire Leak hector. MSI: ❑ Tank Overfill / High -Level Seng. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section Ear Pap 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank im T3: 91 Tank ID: ® In -Tank Gauging Probe. Mord: 847390-109 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794390.409(spik tank) ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 794380-323 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 79431104123 ❑ Fill Sump Sensor(s). Motel: ❑ Mechanical Lire Leak Detector. Model: ❑ Mechanical Lire Irak Detector. Model: ® Electronic Line Leak Detector. Madel: 8484 ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Oder (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 &2 Dispenser ID: 38x4 ® Dispenser Containment Sensor(s). Model: 794380-M IM Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Contairuncirt Float(s) and Choin(s). Omvenser containment Flows) and cham(s). Dispenser ID: 5&6 Dispenser ID: 78x8 ® Dispenser Containment Sensor(s). Model: 794380.323 IN Dispenser Containment Sensor(s). Model: 794380-323 ® Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Ciein(s). Dispenser ID: 9&10 Disperser ID: 11&12 ® Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Sensor(s). Madel: -323 ® Stir Valvc(s). ® she" Valve(s). ❑Dispenser Containment Float(s) and Chain(s). ❑ Dispensar 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, I have also attached a copy of the report, (check all that apple): System set-up Alarm history report Technician Name (print): Guadalupe Sanchez Signa �,.•---asp �-� Certification No.: A30138 License. No.: 1005444 Testing Company Name: Diamond Petroleum Services, Inc. Phone No.: (925) 470-0803 Testing Company Address: 3619 King Ct. Antioch, CA. 94509 Date of Testing/Servicing: 10/19/2016 Page 1 of 4 Rev (2/08)