COMPLIANCE INFO_2016 - 2018 - Laserfiche WebLink

Home Browse Search

a /luf�url! F'Or Use �I''-` ti y Ciled. rha QJ`41!✓rrlsdlcrrons Wrthin r CER TIFICA TION Chaplet-6J,Neallh and ON 1 town must be Safety Code: �Stare o used f0 dJCU Cha ter/ fC:alifornia 1-V1ment testis p 6.q+�'rsion 3, Title 23,Call or n o net by Ute technician who and servicin of 1 nra Code a ntUSt SUbrntt fl rA mJnitprFn e fRegu,.,,n,1A` ' � I0i7 performs the work. A cJp of�hisforn7 must be provided to the rank system owner/ope�-mln I/ copy of f'ortrt to the local agency regulating US'1'sysrems within 30 days of test date 111,211!J r r n m the ,� a A. Generallnformation Facility Name: FE9�'Tt! W CHRTER WAYUNTRY PLACE Site Address: 1789 Facility Contact person; County: SAC,TOA UTN HARP GILL CitY: STOCKTON Make/Model of Monitoring Y S stem: VR-TLS354 Contact Phone g3Q 632-8758 B• Inventory of Equipment Tested/Certified Date of Testing/Servicing: 3/7/t7 FIn-Tank7(G;auging 7 Tank ID: Probe. Model: MAG ❑ In-Tank Gauging Probe. Model: r Vattll Sensor. Model: 420 ❑Annular Space or Vault Sensor, Model: ® Piping Sump 1 Trench SeilSJC(S). Model: 208 ❑Piping Sump/Trench Sensor(.). Modci: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Settsor(s). Model: ®Mechanical Line Leak Detector. Model: LD2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ®Tank Overfill 1 High-Level Sensor, Model: MAG ❑Tank Overfill 1 High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Pale 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: T2-91 Tank CD: ® In-Tank Gauging Probe. Model: MAG ❑ In-Tank Gauging Probe. Model ❑Annular Space or Vault Sensor. Model: ®Annular Space or Vault Sensor. Model: 420 ❑ piping Sump 1 Trench Sensor(s). Model: ®Piping Sump I Trench Sensor(s). Model: 208 Model: Model: ❑Fill Sump Sensor(.). [3Fill Sump Sensor(.). ❑Mechanical Line Leak Detector. Model: ®Mechanical Line Leak Detector. Model: R.1 FX]V f7 Electronic Line Leal:Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model' ®Tank Overfill/high-Levet Sensor. Model: MAG ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(spccify equipment type and model in Section E un Page 21 Dispenser 1D: 718 Dispenser ID: I12 Model: 0li ®Dispenser Containment Sensor(s). Model: Ott ®Dispettser Containment Sensor(.). ®Shear Valve(.). ® ❑Dispenser Containment Float(.)and Chain(s). Shear ValvB(s). ❑ lost(s)and Chain(s). Dispenser Containment Dispenser 1D: 4110 ®Dispenser Containment Sensor(s), Model: 011 Dispenser ID: 314 Model: Ott ®Dispenser Containment Sensor(.). M Shear V alve(s). and Chain(.). ®Shear Valve(.). [j Dispenser Containment Float(s) ❑Dispenser Containment Float(s)and Chain(.). Dispenser lD: 11112 ®Dispenser Containment Sensor(s). Model: Olt Dispenser!L?: 5!6 Modem. Otl ®Dispenser Containment Sensur{s}. ®Shear Valve(s). ®Shear Valve(s). [D Dispenser Containment float(s)and Chain(.). ❑Dispenser Containment Float(s)and Chain(s). Check the appropriate boxes to indicate specific equipment inspcctedlserviced: dance with the tion is information (e.g. manufacturers' checklists) necessaaccor ry verify that C. Certification - s certify that the equipment identified in this document was inspectedlsernct capable of generating such manufacturers' guidelines. Attached to this Certification Alarm history report this information is correct and a Alan showing the layout of monitoring equipment,System set-UP ®n p reports,I have also attached a copy of the report;(check all that apply): Signature: Technician Name(print): JOHN Ll License tune 433159 Certification $47426 Phone No.: (916) 371-2380 Testing Company Name: 8.Z..Service Station Maintenance 605 Date of Testing/Servicing: 317117 Site 1041 Trian le Court West Sacramento CA 95 I of 4 Monitoring Certification Test Report