COMPLIANCE INFO 1998-2006 - Laserfiche WebLink

Home Browse Search

®.. P 7bP7 MONITORING SYSTEM CERTIFICATION Aftr Use By All Jurisdictions Within the State of Calif Authority Cited:Chapter 6.With and Safety Code;Chapter 16,Division 3 Title�alifomfa 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 cedifcatlon or repod 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. a owner operator mus su mi a copy o true oro tote local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: USA#65 City: LODI CA Zip:95242 Site Address: 2500 W.LODI AVE. Contact Phone No:333-9834 LOWER SACRAMENTO RD, Facility Contact Person: MGR-SHARON Date of Testing/Service: 10/10/2001 Make/Model of Monitoring System: TLS350 Work Order Number: 2218951 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1 Tank ID: 2 In-Tank Gauging Probe. Model: 6473 In-Tank Gauging Probe. Model: 8473 71 Annular Space or Vault Sensor. Model: LS3 ZI Annular Space or Vault Sensor. Model: LS3 Piping Sump/Trench Sensor(s). Model: 206 X Piping SumpRrench Sensor(.). Model: 208 Fill Sump Sansor(s). Model: Fill Sump Sensor(.). Model: Mechanical Line Leak Detector. Model: FX1 V 1X1 Mechanical Line Leak Detector. Model: FX1 V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 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). an an 71 In-Tank Gauging Probe. Model: 8473 In-Tank Gauging Probe. Model: 8473 Annular Space or Vault Sensor. Model: LsjAnnular Space or Vault Sensor. Model: LS3 Piping Sump/Trench Sensor(.). Model: Piping Sump/Trench Sensor(.). Model: 208 Fill Sump Sensor(.). Madel: Fill Sump Sensor(s). Model: Mechanical Lina Leak Detector. Model: Mechanical Line Leak Detector. Model: FXIV Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank OveKIVHigh-Level Sensor. Model: Tank OverfiltlHigh-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). 1U. 11Z Spenser ® Dispenser Containment Sensor(.) Model:206 Dispenser Containment Sensor(s) Model:208 ®Shear Velvets). Shear Valve(s) Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(.)and Chain(.). Ispenser Ispenserlid ® Dispenser Containment Sensor(s) Mode1:208 Dispenser Containment Sensor(s). Model:208 ® Shear velvets). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: DispenserlD: 9 ® Dispenser Containment Sensors) Model:208 Dispenser Containment Sensor(s). Model:208 ® Shear Valve(s). Shear Valve(s). ElDispenser Containment Floats)and Chain(s). Dispenser Containment Floats)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 leg manufacturers'checklists)necessary to verify 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:MATT HEMMINGSEN SIGNATURE: 1110w V'Z_--- COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01