COMPLIANCE INFO 2010-2015 - Laserfiche WebLink

Home Browse Search

Appendix VI (Copies of Monitoring system nCertification form and UST Monitoring Plot Plan available at http�//Www.swrcb.ca.gov.) ONITORINGSYSTEM CERTIFICATIOry For Use By All JunSdIMOnS WIMIn the State of CallfOmJa Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations certification or report must be prepared sThis formystem Conmust be used to document testing and trol panel by the technician o performs theent A separate work of oAoopy oring�tnlls form mu be provided to the tank system heh monitoring 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 Bldg. No.: Facility Name: TRACY PETRO City: TRACY Zip: 95376 Site Address: 3408 N.MACARTHUR DR Contact Phone No.: 814$583 Facility Contact Person: KARAM SINGH Date of Testing/Servicing: ZIZV 013 Make/Model of Monitoring System: Veeder Root T1 S-350 B.Inventory of Equipment Tested/Certified Check theappropriate boxes to Indica"s Ac ui menti Ins Taan • kID : T2-REGULAR Tank 10. T1-PREMIUM (� In-Tank Gauging Probe. Model: mag In-Tank Gauging Probe. Model: mag rf Annular Space or Vault Sensor. Model: 302 fi7 Annular 5 c or Vault Sensor. Model: 302 r Piping Sump/Trench Sensor(s). Model: 206 rJ %ping Sump/Trench Sensor(s). Model: 20B r RII Sump Sensor(s). Model: 208 Fill Sump 5Cn5T S). Model: 208 Mechanical Line Leak Detector. Model: Vaporless LD-2000 FJ Mechanical L rte Leak peteetr. Model: Vapodfss LD 2000 r Electronic Line Leak Detector. Model: r Electronic Une Leak Detector. Model: r Tank Overfill/High-Level Sensor.Model: exte nal alarm `r/ Tank Overfill/High-Level Sensor.Model: exlertrol abrin Other s ui e0t and model In Section E on P 2 . Otter ul ent and model in Section E on Pa e 2 . Tank ID: Tank 1D: T3-Diesel r In-Tank Gauging Probe. Model: J7 In-Tank Gauging Probe. Model: mag r Annular Space or Vault Sensor. Model: 17 Annular Space or Vault Sensor. Model: 3D2 r Piping Sump/Trench Sensor(s). Model: J piping Sump J Trench Sensor(s). Model: 208 r Fill Sump SenSil s). Model: F FIII Sumo Sensor(s). Model: 208 Mechanical Une Leak De[ectr. Model: rr/ Mechanical Une Leak Detector. Model: Vapodess LD-2000 r Electronic Line Leak Detector. Model: I— Electronic Line Leak Detector. Model: r Tank Overfill/High-Level Sensor.Model: Tank Overfill/High-Level Sensor.Model: externaldlaalarmOther s � ui ent and model innSectio n E on Pae 2. Dispenser d ul menti and motlel in Section E on 2. 3/4 Dispenser 1/2 ID: ID: 208 Dispenser Containment Sensor(s).Model: ri Dispenser Containment Sensor(s).Model: 206 r Shear Valve(s). 17 Shear Valve(s). r Dispenser Containment Floats and Chains . Di Dispenser Containment Floats dna Chains. Dispenser Dispenser 7/8 5/6 ID: ID: �,7 Dispenser Containment Sensor(s).Model: R Dispenser Corrtainment Sensor(s).Model: 208 F Shear Valve(s). Pr Shear Valve(s). Dispenser Containment Floc s and Chain s . Dispenser Containment Floats and Chains. Dispenser Dispenser 1D: ID: r Dispenser Containment Sensor(s).Model: r Dispenser Containment Sensor(s).Model: r Shear Valve(s). r Shear Valve(s). Di nser Containment Fl s and Chaln s. Dis nwr Cattalnment Roots and Chains. •If the fadllty contains more tanks or dispensers,copy this form.Indude Information for every tank aM dispenser a[the facility. C.CertiNcation-I certify that the equipment identified in this document was impected/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 Plat 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}r System set- up 17 Alarm history report nn- Technician Name(print): Steven Willens Signature: Certification No.: 936743 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)8004633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 - Date of Testing/Servicing: 2/242013 Monitoring System Certification Page 1 of 3 12/07