COMPLIANCE INFO_2016 - 2018 - Laserfiche WebLink

Home Browse Search

Appendix VI REGEAvtu FEB 12 20% ENVIRONMENTAL HEALTH PERMIT/SERVICES (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httD://www.waterboards.ca.aov.) 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 certification or report must be prepared for each monitoring system control panel by the technician who perforins 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: Pershing Gas Bldg. No.: Site Address: 4445 Pershing Avenue City: Stockton Zip: 95207 Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1/28/2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ectecilserviced: Tank to: 1 UNLEADED Tank to DIESEL N In -Tank Gauging Probe. Model: MAG J In -Tank Gauging Probe. ModeLMAG J Annular Space or Vault Sensor. ModeLVR 302 J Annular Space or Vault Sensor. ModeLVR 302 J Piping Sump / Trench Sensor(s). Model:VR 352 J Piping Sump / Trench Sensor(s). Model: VR 352 Fill Sump Sensor(s). Model: -„ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: J Electronic Line Leak Detector. Model: PLLD J Electronic Line Leak Detector. ModeLPLLD _ 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 t e and model in Section E on Pae 2). Tank ID:2 PREMIUM Tank ID: J In -Tank Gauging Probe. Model: MAG n In -Tank Gauging Probe. Model: J Annular Space or Vault Sensor. Model: VR 302 ❑ Annular Space or Vault Sensor. Model: 'iping Sump / Trench Sensor(s). Model: VR 352 ❑ Piping Sump / Trench Sensor(s). Model: IliiswFill Sump Sensor(.). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model:PLLD ❑ Electronic Line Leak Detector. Model: J Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pae 2). ❑ Other (specify equipment a and model in Section E on Page 2). Dispenser to: 1/2 Dispenser to: 7/8 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). J Dispenser Containment Floats and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser ID: 3/4 DispenserlD: 9/10 ❑ Dispenser Containment Sensor(s). Model: n Dispenser Containment Sensor(s). Model: ❑ Shear Velve(s). ❑ Shear Valve(s). J Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser to: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). J Dispenser Containment Floats and Chains I n Dispenser Containment Floats and ChainLsl_ 'If the facility contains more tanks or dispensers, copy this forth. 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): System set-up Alargriltisjory report Technician Name (print): JAMES DAY Signatur r Certification No.: A22740 License..: 9 985 Testing Company Name: MID VALLEY CONSULTING Phone No.:(530) 49-9892 Testing Company Address: 1097 BRONCO DRIVE, PLUMAS LAKE, CA95961 Date of Testing/Servicing: 1/28/2016 Monitoring System Certification Page f of 4 k 12/07 2/21!07