COMPLIANCE INFO_2016-2018 - Laserfiche WebLink

Home Browse Search

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 monitoriP ui ment. A s ra a certification or report must be re ared for each monitoring sstem control panel by the technician whits s w t ust be provided to the tank system owner/operator. The owner/operator must submit a co of this form tsf,3il ct ste s ithin 30 days of test date. A. General Information MAR 16 2017 Facility Name: ARCO Bldg.No.: Site Address: 4855S.State Route 99 EIVIRONMEN LCiry' ton,Ca. Zip: 95215 Facility Contact Person: Gill FH1Ci_%W&U Phone No.: (209) 481-7445 Make/Model of Monitoring System: Veeder Root TLSjgjPAFMMEWDate of Testing/Servicing: 11/25/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates cific equipment inspected/serviced. Tank ID: 87 Tank ID: 89 Z In-Tank Gauging Probe. Model: 847390-109 Z In-Tank Gauging Probe. Model: 847390.109 Z Annular Space or Vault Sensor. Model: 794390.407 Z Annular Space or Vault Sensor. Model: 794390-407 Z Piping Sump/Trench Sensor(s). Model: 794380-323 Z Piping Sump/Trench Sensor(s). Model: 79438D-323 Z Fill Sump Sensor(s). Model: 794380-344 Z Fill Sump Sensor(s). Model: 794380323 ❑Mechanical Line Leak Detector. Model: Z Mechanical Line Leak Detector. Model: 99LD-2000 Z Electronic Line Leak Detector. Model: RJ 244-006-5 ❑ Electronic Linc 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). Tank to: 91 Tank ID: Z In-Tank Gauging Probe. Model: 847390-109 ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor, Model: 794390-407 ❑Annular Space or Vault Sensor. Model: Z Piping Sump/Trench Sensor(s). Model: 794380-323 ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: 794380-323 ❑Fill Sump Sensar(s). Model: Z Mechanical Line Leak Detector. Model: 99LD-2000 ❑Mechanical Line Leak Detector. Model: ❑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). Dispenser ID: 1&2 Dispenser ID: 3&4 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Seasons). .Model: 794380323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Flom(s)and Chain(s). ❑Dispenser Containment Floats)and Chain(s). Dispenser ID: 58,6 Dispenser ID: 7&8 Z Dispenser Containment Sensor(s). Model: 794380-323 Z Dispenser Containment Seusor(s). Model: 794380323 Z Shear Valve(s). Z Shear Valve(s). ❑Dispenser Containment Flost(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9&10; 11&12 Dispenser ID: 13&14; 16&16; 17&18 Z Dispenser Containment Seasons). Model: 794380-323 Z Dispenser Containment Scnaor(s). Model: 794380-323 Z Shear Valve(s). Z 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 77c 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 equi ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ®System set-up El Alarm history report J Technician Name(print): Guadalupe Sanchez Signatuw. 4 Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 11930 Horseshoe Rd, Oakdale,Ca.95361 Date of Testing/Servicing: 11/25/2014 Page 1 of 4 Rev(2/08)