COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hftp://www.waterboards.ca.gov) Monitoring System Certification For Use By All Jurisdictions Within the State of California A �� Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califom f D This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be 13Eprepared for eac monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank stem 2 2 n`�erlop, rrator. The Ut1, owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. t ✓ 2010 A. General Information Facility: Pacific Bell Telephone Co. dba AT&T California GEO PAR # UE656 ENVIRONMENT Address: 44 W. YOKUTS City: STOCKTON PERMIT.o Facility Contact Person: Connie Mitchell Contact Phone No: 209-598-5155 Make/Model of Monitoring System: Veeder-Root TLS -350 Service Date: 12/13/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: UE656AO01 Tank ID: ® In -Tank Gauging Probe Model:847390-105 ❑ In -Tank Gauging Probe Model: Annular Space or Vault Sensor Model:794390-420 ❑ Annular Space or Vault Sensor Model: ❑ 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 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 E on Page 2) TanklD: TanklD: ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ 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 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: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(s) ❑ Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ID: DispenserlD: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(s) ❑ Shear Valve(s) ❑ 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(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 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 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 Technician Name (Print): John Cascio Si nature: Certification No: B35337 License No: 098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No: 714 560-8222 TestingCompany Address: 2131 South Dupont Drive Anaheim, CA 92806 Date of Testing/Servicing: 12/13/2010 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07