COMPLIANCE INFO_2016 - 2018 - Laserfiche WebLink

Home Browse Search

Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httD://www.waterboards.ca.gov.) 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 performs the work. A copy of this forth 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: FAST AND EASY Bldg.No.: Site Address: 10878 N.HWY 99 City: STOCTON CA, Zip: 95212 Facility Contact Person: MIKE ALE Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 412512016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID:1 SUPREME Tank ID: UNLEADED X In-Tank Gauging Probe. Model:VR MAG PROB X In-Tank Gauging Probe. Model: VR MAG PROB X Annular Space or Vault Sensor. Model:VR 420 X Annular Space or Vault Sensor. Model: VR 420 X Piping Sump/Trench Sensor(s). Model:VR 208 X Piping Sump/Trench Sensor(s). Model: VR 208 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model:RED JACKET FXIV X Mechanical Line Leak Detector. Model: RED JACKET FXIV ❑ 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 a and model in Section E on Page 2). 0 Other(spedly(spedequipment t e and model in Section E on Page 2). Tank 10:2 PLUS Tank ID: DIESEL X In-Tank Gauging Probe. Model:VR MAG PROB X In-Tank Gauging Probe. Model: VR MAG PROB X Annular Space or Vault Sensor. Model:VR 420 X Annular Space or Vault Sensor. Model: VR 420 X Piping Sump/Trench Sensor(s). Model:VR 208 X Piping Sump/Trench Sensor(s). Model: VR 208 Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model:VMI LD 2000 X Mechanical Line Leak Detector. Model:RED JACKET FXIV ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill I High-Level Sensor. Model: ❑ Tank Overall/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pane 2). ❑ Other(specify equipment t e and model in Section E on Pane 2). Dispenser ID:1/2 Dispenser ID:7/8 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). X Dispenser Containment Floats and Chain(s).BROVO X Dispenser Containment Floats and Chain(s).BROVO Dispenser ID:3/4 DispenserlD: 9110 n Dispenser Containment Sensor(s). Model: 7 Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s). X Dispenser Containment Floats and Chain(s).BROVO Dispenser Containment Floats and Chain(s). Dispenser ID:5/6 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shearvalve(s). X Dispenser Containment Floats and Chains BROVO ❑ Dispenser Containment Floats and Chains. `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 ❑Alarm history report Technician Name(print):JASON HAASE Signature: Certification No.: B40970 License.No.: 920985 Testing Company Name:MID VALLEY CONSULTING Phone No.:(530)749-9892 Testing Company Address: 1097 BRONCO DRIVE,PLUMAS LAKE,CA 95961 Date of Testing/Servicing: 4125/2016 Monitoring System Certification Page 1 of 4 12107 1 2/21/07