COMPLIANCE INFO 2000-2005 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION � ip TanknakW rUse By All Jurisdictions Within the State of Calif, Authority Cited.Chapter 6. e/th and Safety Code;Chapter 16, Division 3 Title a/ifomia 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 mons onng system control panel by the technician who performs the work. A copy of this form must be provided to the tank sys em owner operator. a owner opera r mus su ml a copy o is ortn o e local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: ULTRAMAR492 City: MANTECA CA Zip:95336 Site Address: 470 N MAIN ST Contact Phone No:823-1344 Date of Testing/Service: 12/12/2002 Facility Contact Person: MANAGER Make/Model of Monitoring System: GBCO EMC Work Order Number: 2224699 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: UNLEADED Tank ID: SUPREME In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: MAG Annular Space or Vault Sensor. Model: GBCO 010 X Annular Space or Vault Sensor. Model: GBCO 010 Piping Sump/Trench Sensor(s). Model: GBCO 000 X Piping Sumprriench Sensor(s). Model: GBCO 000 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Madel: Mechanical Line Leak Detector. Model: RJ FX1 V X Mechanical Line Leak Detector. Model.. RJ FX1V Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overrill/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 In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sumpfrrench Sensor(s). Model: Piping Sumpri-rench 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 Overall/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). Dispenser lu. Spenser ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensors) Model: ®Shear Valve(s). Shear Valve(s) ®Dispenser Containment Float(s)and Chaints). Dispenser Containment Float(s)and Chain(s). Dispenser Ispenser ❑ Dispenser Containment Sensors) 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: F] 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). 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 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:KEVIN MATLOCK SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01