COMPLIANCE INFO 2011 - 2016 - Laserfiche WebLink

Home Browse Search

0 • RECEIVED Appendix VI t (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.cf .J x 201¢ MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions Within the State of California HEALTH DPMMENT Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code o 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: CHEVRON 210997 (N-4693) Bldg. No.: Site Address: 1442A COLONY DR. Facility Contact Person: PATTY Make/Model of Monitoring System: Veeder Root TL5 350 B. Inventory of Equipment Tested/Certified City: RIPON Contact Phone No.: 209-599-0149 Zip: 95366 Date of Testing/Servicing: 2/3/2014 Tank ID: T1:SUPREME UNLEADED - PREMIUM Tank ID: T2:REGULAR UNLEADED - REGULAR In -Tank Gauging Probe. Model: mag r In -Tank Gauging Probe. Model: mag r Annular Space or Vault Sensor. Model: 409 W Annular Space or Vault Sensor. Model: 409 r Piping Sump / Trench Sensor(s). Model: 208 [i- Piping Sump / Trench Sensor(s), Model: 208 r Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model R" Mechanical Line Leak Detector. Model: rW Electronic Line Leak Detector, Model: Veeder Root PLLD v Electronic Line Leak Detector. Model: Veeder Root PLLD 17 Tank Overfill / High -Level Sensor. Model: flapper/ext alarm r Tank Overfill / High -Level Sensor. Model: flapper ext alarm r Other(specify equipment a and model in Section E on Pae Other(specify equipment a and model in Section E on Pae 2). Tank IID: Tank ID: r In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: 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: r 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). Other(specify equipment a and model in Section E on Pae 2L__ Dispenser 1/2 Dispenser 3/4 ID: ID: r" Dispenser Containment Sensor(s). Model: 208 [7 Dispenser Containment Sensor(s). Model: 208 W Shear Valve(s). Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5J6 Dispenser 7/8 I0: ID: Dispenser Containment Sensor(s). Model: 208 fV_ Dispenser Containment Sensor(s). Model; 208 Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9110 Dispenser 11/12 ID: ID: JV Dispenser Containment Sensor(s). Model: 208 rV Dispenser Containment Sensor(s). Model: 208 r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). *It the tacility contains more CanKs or alspensers, CUpy Lr115 Milk iiluuuc uuuoinauuii iur cvcl y wnn aur 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 P Alarm history report Technician Name (print): Jarrod Cooke Certification No.: 5311523 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification License. No. Signature: 743160 Class'A' Phone No.: (800) 800-4633 Page 1 of 3 Date of Testing/Servicing: 2/3/2014 12/07