COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

Appendix VI 0 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:#www.water a.R MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California FEB 2 12017 Authority Cited. Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations This tori must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for eacl monitoring system control panel by the technician who performs flee work. A copy of this form must be provided to the tank system d � owner/operator must submit a copy o fthis form to the local agency regulating UST systems within 30 days of test date. 4 8 DEPA iTME('-, A. General Information Facility Name: Pacific Bell Telephone Co dba ATT California Facility ID: UG010 Site Address: 1812 Coley Ave. City: Escalon Facility Contact Person: Thuy Tran Make/Model of Monitoring System: Veeder Root TLS -350 Plus Zip: 95320 Contact Phone No.: (209) 532-3447 Date of Testing/Servicing: 2/3/2017 B. Inventory of Equipment Tested/Certified Check the aDDroDriate boxes to indicate specific equipment inspected/serviced: Tank ID: 0001 00001 Tank ID: ❑ In -Tank Gauging Probe. Model: 0 In -Tank Gauging Probe. Model: 847390-103/ 731089 Annular Space or Vault Sensor. Model: 794390-420/ 490104 ❑ Annular Space or Vault Sensor. Model: Ful Piping Sump/ Trench Sensor(s). Model: 794380-208/515978 ❑ 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 Lune Leak Detector. Model: Tank Overfill /High -Level Sensor. Model: 790091-001 ❑ Tank Overfill/ High -Level Sensor. Model: Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section on Page 2). Tank ID: Tank ID: In -Tank Gauging Probe. Model: ® In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: j ❑ Piping Sump / Trench Sensor(s). Model: ❑ 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. i Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / Hiah-Level Sensor. Model: ❑Other s eci equipment t e and model in Section E on Page 2 (p fytype g )• Other s eci equipment t e and model in Section E on Page 2 ❑ (p 15')'p g )• Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). EIS he,, Valve(,). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(,). ❑ Shear Valve(',). ❑ Dispenser Containment Float(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 correctand 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 appty) : ❑X System set-up ❑^ Alarm history report Technician Name (print): Garrett Warren L� vCii� g Signature: Certification No.: B42126 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 sou-MDuroN• ERfVE, ANAM KCAmso6 Date of Testing/Servicing: 2/3/2017