COMPLIANCE INFO 2010-2015 - Laserfiche WebLink

Home Browse Search

Appendix VI RECEIVED (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://Www.swreb.ca.gov.) MONITORING SYSTEM CERTIFICATION APR 01 2014 For Use By All Jurisdictions Within the State of California NMENTAL Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, Cal/for DEPARTMENT Regulations 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: TRACY PETRO Bldg.No.: Site Address: 3400 N.MACARTHUR DR City: TRACY Zip: 95376 Facility Contact Person: KARAM SINGH Contact Phone No.: 209-814-8581 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 2/21/2014 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: TI-PREMIUM Tank ID: T3-Diesel rV In-Tank Gauging Probe. Model: mag r' In-Tank Gauging Probe. Model: mag Annular Space or Vault Sensor. Model: 303 W: Annular Space or Vault Sensor. Model: 303 (70 Piping Sump/Trench Sensor(s). Model: 208 P-0 Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: 208 r Mechanical Line Leak Detector. Model: Vaporiess LD-2000 ry—,. Mechanical Line Leak Detector. Model: Vaporless LD-2000 r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: WO Tank Overfill/High-Level Sensor.Model flapper (✓• Tank Overfill/High-Level Sensor.Model: flapper Other(specify equipment a and model in Section E on Pa e 2 . Others ui ment type and model in Section E on Pae 2). Tank ID: T2-REGULAR Tank ID: WO In-Tank Gauging Probe. Model: mag r In-Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: 303 r Annular Space or Vault Sensor. Model: (1/_ Piping Sump/Trench Sensor(s). Model: 208 r Piping Sump/Trench Sensor(s). Model: WO Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: P Mechanical Line Leak Detector. Model: Vapodess LD-2000 r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill/High-Level Sensor.Model flapper r Tank Overfill/High-Level Sensor.Model: Other(specify equipment type a r Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 7/8 ID: ID: r7 Dispenser Containment Sensor(s).Model: 208 WO Dispenser Containment Sensor(s).Model: 208 Shear Valve(s). r Shear Valve(s). r Dispenser Containment Floats and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser 3/4 Dispenser ID: ID: r Dispenser Containment Sensor(s).Model: 208 r Dispenser Containment Sensor(s).Model: W Shear Valve(s). r Shear Valve(s). r Dispenser Containment Floats and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser 5/6 Dispenser ID: ID: P-0 Dispenser Containment Sensor(s).Model: 208 r Dispenser Containment Sensor(s).Model: WO Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this forn.Include information for every tank and dispenser at the facility. C.Certification-I certfy that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines.Attached to this Certification is information(e.g.manufacturerschecklists)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 appal.r.System set- up r Alarm history report Technician Name(print): Brent Bowen Signature: Certification No.: 842815 License.No.: 7431600a5 'A Testing Company Name: Tanknology Phone No.: (800)BOD4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 2/21/2014 Monitoring System Certification Page 1 of 3 12/07