COMPLIANCE INFO 1998-2004 - Laserfiche WebLink

Home Browse Search

_ MONITORING SYSTEM CERTIFICATION ® 1P. or Use By All Jurisdictions Within the State of Califo a Authority Cited:Chapter 6.0alth and Safety Code;Chapter 16,Ofvlsion 3 Title alifomia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,a separate certification or report must be prepared for each monitonng system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner opere or. a owner operetor must su mit a copy o t s rtn o t -local agency regulating UST systems within 30 days of test date. A.General Information CA Zip:95376 Facility Name: ULTRAMAR 698 City: TRACY Site Address: 153 E 11TH ST Contact Phone No:832-8815 Date of Testing/Service: 02/07/2002 Facility Contact Person: MGR-CHELA Make/Model of Monitoring System: GILBARCO EMC Work Order Number: 2220769 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TankiD: 1 TanklD: 2 In-Tank Gauging Probe. Model: 2650960200 In-Tank Gauging Probe. Model: 2650960200 Annular Space or Vauk Sensor. Model: 794380420 X Annular Space or Vauk Sensor. Model: 2591144000 Piping Sumprrmnch Sensor(s). Model: 2592000010 X Piping Sump/Trench Sensor(s). Model: 2592000010 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FXt V X Mechanical Line Leak Detector. Model: FX1 V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OverflllHigh-Level Sensor, Model: ATG X Tank OverglUHigh-Level Sensor. Model: ATG Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). an an In-Tank Gauging Probe. Model: 2650960200 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sumprrmnch Sensor(s). Model: 2592000010 Piping SumprTrench Sensor(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: Tank OverfiltlHigh-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). spenser Dispenser Containment Sensor(s) Madel: Dispenser Containment Sensor(s) Model: ® se Shear Valve(s). Dispenser r Containment Floats)and Chain(s). C(e) ® Dispenser Containment Float(s)and Chain(s). Dispenser enser . Ispenser Isp Dispenser Containment Sensors) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). ® Shear Valve(s). Dispenser Containment Floal(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: DispenserlD: F] Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). ElDispenser Containment Floats)and Chain(s). 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 verity that this information Is correct. and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): System set-up report; ® Alarm history report PRINTED NAME: JEFF CONGER SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page t of 3 Based on CA form dated 03/01