COMPLIANCE INFO 2001 - 2009 - Laserfiche WebLink

Home Browse Search

MORING SYSTEM CERTI WATION For Use By All Jurisdictions Within the State of California Aterhority Cited: Chapter 6 7, Health and Safety Code,- Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipollent. 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 summit a cope of this fordo to the local (}e j 1t 'stems within 30 days of test date. `��11�i 1� t l' A. General Information Facility'Name: _Sprint Stockton, CA Switch (San Joaquin Count)- Bldg. .: EC �� Ci Stockton Zi 95204 =zv Site Address: anor t5-_ - MEW HEALTH Facility Contacterson Ron_Williams Contact Phone No.: (_209-93 7-5$"ffiLMBVICES Make/Model of Monitoring System: TLS 300 Date of Testing/Servicing: 11/13/03 B. Inventory of Equipment Tested/Certified 4 Check the approypriate iwte+to indicate, eific ui ent iW;Pectedbqelti iced Tank ID: Diesel 41 underground Tank ID: ■ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: s Annular Space or Vault Sensor. Model: ElAnnular Space or Vault Sensor, Model: C3Piping Sump/Trench Sensor(s), Model: ❑ Piping Sump/Trench Sensolf 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: j ■ Tank Overfill/Fligh-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ tither(s ih - ui ment t\z and model in Section E on Page 2). ❑ (alter(5 its tui ment riz and model in Section E on Pace Z} Tank ED: Tank 1D• ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Slunp/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Z) Fill Stump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Madel: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/Iligh-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(a cili Nui2rnent h and model in Section E on Pale 2 . ❑ Other fs iti ui mens t� and model in Section E an.Pane 2). Dispenser ID: Dispenser ID ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Disinser Containment Floats and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment,Sensor(s). Model: I ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valve(s). ❑ Shear Valve(s). oo ❑ Dls ser Containment F'loatfs)and Chain(s). ❑ Dis ser Containment Float(s)ts and Chain(s). Dispenser ID: Dispenser ED ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shed,Valve(s). ❑Dis user Containment Floatf s� and Chain(s). I ❑ Di s r Containment Float(s)and Chain(s). +If the facility contains more tanks or dispensers,copy this form. Include information for even 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.9- manufacturers' checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment r any equipment capable of generating such reports,I have also attached a copy of the repo , leeck all tl�ut uppty): ❑ syst set-up, D Alarm history report Technician Name{ riot): Signature. Testing Company ane:_L.AArks Plumbing&Heating Inc. Phone 75 _3-5 -4403 SiteAddress: ,7 Date of Testing/Servicing:�11/I3/03 Pae 1 of 3 0/til Nevada License 12359A Classification 1,unhnuted Eevada License 12559 Classifications A15,16.19,ZZ lint 35.000,000 Nevada License 12539C Classifications B2,4lutvt 35,000,000 Calsfortua Licensc 6704n Classifications A,C-36,ILII Oregon Ltccnsc 147496 Nevada Undergound Handlers L cause 1015