COMPLIANCE INFO_2018 - Laserfiche WebLink

Home Browse Search

Appendix VI ,40 E D MONITORING SYSTEM CERTIFICATION JUS 21`3 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 14\11VI )WENTAL Regulations a PARiI��t [� (4Lsl . [ n r 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 UST systems within 30 days of test date. A. General Information Facility Name: ORLANDO'S Site Address: 18754 HWY 26 City: Facility Contact Person: BRANDON Make/Model of Monitoring System VEEDER ROOT TLS350 Bldg. No.: LINDEN Zip: 95236 Contact Phone No.: ( ) B. Inventory of Equipment Tested/Certified Chprk the annrnnriate boxes to indicate specific eauinment Insoected/serviced: Date of Testing/Servicing: 7/10/18 `If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility, TanklD: 91 TankID: 87 N In -Tank Gauging Probe, Model: MAG 1 N In -Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 420 N Annular Space or Vault Sensor, Model: 420 N Piping Sump/ Trench Sensor(s), Model: 208 N Piping Sump/ Trench Sensor(s), Model: 208 N Fill Sump Sensor(s), Model: 208 N Fill Sump Sensor(s). Model: 208 N Mechanical Line Leak Detector. Model: 99LD2000 N Mechanical Line Leak Detector. Model: 99LD2000 ElElectronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: N Tank Overfill / High -Level Sensor, Model: 90% N Tank Overfill / High -Level Sensor, Model: 90% [IOther (specify equipment type and model in Section E on Page 2). ElOther (specify equipment type and model in Section E on Page 2), Tank ID: Tank ID: DIESEL N In -Tank Gauging Probe. Model: MAG 1 El In-TankGauging Probe, Model: N Annular Space or Vault Sensor. Model: 420 E]Annular Space or Vault Sensor, Model: N Piping Sump/ Trench Sensor(s). Model: 208 ❑ Piping Sump / Trench Sensor(s). Model: ElFill Sump Sensor(s). Model: [IFill Sump Sensor(s). Model: N Mechanical Line Leak Detector, Model: 99LD2000 ElMechanical Line Leak Detector, Model: E]Electronic Line Leak Detector, Model: E]Electronic Line Leak Detector, Model: N ❑ Tank Overfill / High -Level Sensor, Other (specify equipment type and model Model: 90% in Section E on Page 2). E]Tank ElOther Overfill / High -Level Sensor. Model: (specify equipment type and model in Section E on Page 2), Dispenser ID: 34 Dispenser ID: 1-2 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s), Model: 208 N Shear Valve(s). N Shear Valve(s). ElDispenser Containment Float(s) and Chain(s). E]Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 N Dispenser Containment Sensor(s), Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). E]Dispenser Containment Float(s) and Chain(s). ElDispenser Containment Float(s) and Chain(s). Dispenser ID: 11-12 Dispenser ID: 9-10 ® Dispenser Containment N Dispenser Containment Sensor(s). Model: 208 Sensor(s), Model: 208 N Shear Valve(s). ® Shear Valve(s). E]Dispenser Containment Float(s) and Chain(s). E]Dispenser Containment Float(s) and Chain(s). 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): ®System set-up ®Alarm history report ;'It Cert Technician Name (print): FELIX RAMIREZ ification No.: 8883072 -UT Testing Company Name: AFFORDA-TEST Testing Company Address: 416 2nd STREET GALT, CA 95632 Monitoring System Cert ification Signature: License No: 08-1740 Phone No. (209) 744-0113 Date of Testing/Servicing: 07-10-18 Page 1 of 4 2/21/07