COMPLIANCE INFO_2010 - 2015 - Laserfiche WebLink

Home Browse Search

0 Appendix VI MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority 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 equipment.A separate ceriificatien 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 LST systems within 30 days of test date. A. General Information N.crnloy GEORGE'S MINI MART Bldg.N0.: Site Address i8662 N. HWY 88 City: LOCKEFORD Zip: 95237 Facility Contact Person, Contact Phone No.: MakelModel of Monitoring System: GILBARCO EMC Date of Testing/Servicing: 6!16!2012 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate specific equipment inspectedlserviced: Tank ID: 87 Tank Size: Tank ID. 89 Tank Size: In-Tank Gauging Probe. Model_ MAG 2 0 In-Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 ® Annular Space or Vault Sensor Model: 420 Piping Sump/Trench Sensor(s). Model: 205 ® Piping Sump/Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: ® Mechanical Line Leak Detector. Model: STP-MLD Z Mechanical Line teak Detector. Model: STP-MLD ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Medet: ❑ Tank Overfill/High-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). Tank ID: DIE Tank Size: Tank ID 91 Tank Size: 0 In-Tank Gauging Probe. Model: MAG 2 ® In-Tank Gauging Probe. Model: MAG I ® Annular Space or Vault Sensor. Model: 420 Z Annular Space or Vault Sensor. Moder, Same as 89 Tani: ® Piping Sump/Trench Sensor(s), Model: 205 0 Piping Sump/Trench Seasor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: ❑ Mechanical Line Leak Detector. Model: 99 LD 2000 0 Mechanical Line Leak Detector. Model: STA-MLD ❑ Electronic Line Leak Detector Model, ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: ❑ Tank Overfill I High-Level Sensor. Model: Other(specify equipment type and mode[in Section E on Page 2) ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser to 1/2 Dispenser ID: 3A ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 718 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® ShearValve(s), ® ShearValve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 9 SATELITE & 10 SATELITE ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model. Z Shear Valve(s). ® Shear Valve(s). ® Dispenser Containment Float(s)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 inspectecilserviced 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;(clreck rill mal apply): ®System set-up 9 Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A26446 License No: 04.1676 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2 STREET GALT,CA 95632 Date of TestinglServicing: 5/15/12 Monitoring System Certification Page 1 of 4 2/21/07