COMPLIANCE INFO_2007-2015 - Laserfiche WebLink

Home Browse Search

a ONI NG SYSTEM CETIF ATION ;� For Use By All Jurisdictions Within the State of California AY Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Cod dations r( This form must be used to document testing and servicing of monitoring equipment. A separate certification or rt mus ' r ch monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system o The owner/operator must submit a ca of this form to the local " j - copy agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Shell 1-5 Bldg. No.: Site Address: 717-W. Eighth St. City: Stockton, Ca. Zip: 95206 Facility Contact Person: Joe Dangtran Contact Phone No.: (209) 939-0961 Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 4/28/2012 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate simcific equipment inspected/serviced: k ID: T1: 87 Tank ID: T2.91 n -Tank Gauging Probe. Model: 847390-109 rosErIlPliping ® In -Tank Gauging Probe. Model: 847390-109 nnular Space or Vault Sensor. Model: 794380-303 ® Annular Space or Vault Sensor. Model: 794380.303(split Tank) Sump / Trench Sensor(s). Model: 794380-208 ® Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Mechanical Line Leak Detector. Model: 99LD-2000 ® Mechanical Line Leak Detector. Model: FX1 V ❑ 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 type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2), Tank ID: T3: Diesel Tank ID: ® In -Tank Gauging Probe. Model: 847390-109 ❑ In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: 794380-303(split tank) ❑ Annular Space or Vault Sensor. Model: ® Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Piping Sump / Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: 794380-203 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: FX1 DV ❑ 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 type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: %2 Dispenser ID: 3&4 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). Sam ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9&10 Dispenser ID: 11&12 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ 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 disnenser at -.he ftrility 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 equi ment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check aU that arly): System set-up Alarm histo report Technician Name (print): Guadalupe Sanchez Signa Certification No.: A30138 License. No.: 883706 01 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.: (209) 845-8586 Testing Company Address: 11930 Horseshoe Rd. Oakdale, Ca.95361 Date of Testing/Servicing: 3128/2012 Page 1 of 4 Rev (2/08)