COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Appendix VI RECEIVED (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://WWW.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION DEC 0 5 2014 For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, Title— Regulations DEPARTMENT 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: CA-124 Bldg. No.: Site Address: 3663 Peterson Road City: STockton Zip: 95215 Facility Contact Person: Contact Phone No.: - Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 10/3/2014 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected serviced: Tank ID: TI:Diesel10K-Diesel Tank ID: T2:Diesel10K-Diesel In-Tank Gauging Probe. Model: 846390-107 f 71 In-Tank Gauging Probe. Model: 846390-107 Annular Space or Vault Sensor. Model: 794390-420 r Annular Space or Vault Sensor. Model: 794390-420 F Piping Sump/Trench Sensor(s). Model: r Piping Sump/Trench Sensor(s). Model: F Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: (— Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor.Model: Mag Probe 170 Tank Overfill/High-Level Sensor.Model: Mag Probe r Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pa e 2). Tank ID: T3 : EXFLUID-Diesel Exhaust Fluid Tank ID: In-Tank Gauging Probe. Model: Unknown (� In-Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump/Trench Sensor(s). Model: r Piping Sump/Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: IW Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: 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: r Tank Overfill/High-Level Sensor.Model: Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pae 2). Dispenser 1 Dispenser 2 ID: ID: r Dispenser Containment Sensor(s).Model: r Dispenser Containment Sensor(s).Model: F Shear Valve(s). r Shear Valve(s). I- Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser lsat Dispenser 7sat ID: ID: r Dispenser Containment Sensor(s).Model: r Dispenser Containment Sensor(s).Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s).Model: r Dispenser Containment Sensor(s).Model: r 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 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):r System set- up r Alarm history report Technician Name(print): Darren Sciume Signature: Certification No.: 835390 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: 10/3/2014 Monitoring System Certification Page 1 of 3 12/07