COMPLIANCE INFO 2008 - 2015 - Laserfiche WebLink

Home Browse Search

MONI1%JNG SYSTEM CERTIFISTION For Uxe By All Jurtadictionr Within the,State of California Auth ria+Cited,' Chapter-6.7, Health and Safety Code; Chapter 16. Division 3, Title 23, California Coele of Regulations This form tr List be used to document testing and servicing of monitoring equipment,Aeparatecertification or report must be prepared for each m itoriN system control aMl by the technician who performs the work. A copy of this form 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. Genelral Information Facility Na c:Systems Transport Bldg.No.: Shop Site Addres707 E.Roth Road City: French Camp Zip 95231 Facility Contact Person: Steve Tucker Contact Phone No.: (209)983-8062 Make/Mudol of Monitoring System;Veeder-Root TLS-350 Date ofTesting/Servicing; May 17,2010 13. Inventory of Equipment Tested/Certified Cbeek nicnporoUiate boxes it,indicate s ccilic Unit meat'11911ected/4e'vleed:Tank ID: #1 DIESEL Tank In.I'ank Gsuging Probe. Model: Q In-Tank Gauging Probe. -Model: (x)Annular Spacc or Vault Sensor. Model: 794390-407 ❑ Annular Space or Vault Sensor, Model: -_ ( )Piping Sump/ rrench Sensonts). Model: 794380-208 ❑ Piping Sump/ I rcnch Sensor(s). Model: ❑ Fill SumpSensor(s), Model: N/A CI Fill Sump Scnsor(s)_ Model:,, -_- (x)Mechani 111 e Leak Dowwor. Model: VMI I,D-2000 ❑ Mechanical Linc Leak Dotcclor. Model: U Kluctroni Linc Look Detector Model: ❑ Electronic Linc Leak Detector. Model: ❑ 'Tank Ov lilt t I Iigh-Level Senso,. Model: O 'rank Overfill/High-Level Sensor. Model: Ll Othersoily c u�i foment lY nand model in Section E on P e 2 . [3 other(specify equipment type and model in Section ti on Page 2). Tank 10: A P. Tank 10: -- ( )In--'tank auging Probe, Model: ❑ In-Tank Gauging Probe. Model: _ Annular pace or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping St mp/Trench Scnsor(s). Model:_ - .._ ❑ Piping Sump/Trench Scnsur(s). Model: 13 Fill Sunil Scnsot(s). Model: .,, ❑ Fill Sump Scnsor(s). Model: ❑ Mecham al Line Leak Detector, Model:_ _ __ ❑ Mechanical Linc Leak Detector. Madel:__. ❑ Cleclmni i.inc Leak Detector, Model'—., ❑ Electronic Linc I,eak Detector, Model: o 'rank Overlill; High.-Levet Semler. Model: ,. ❑ Tank Overfill/High-Level Sensor. Model: -_ ❑ Other s city aqui menl type and model in Section E on P2ge22 Other(s eci et ui ment t e and modd in Section E on P o 21. Dispenser In: SATELI,ITF #1 Dispenser ID: ._. ...._ (x)Dispenser Containment Scnson s). Model; 794380-208 12 Dispenser Containment Scttsor(s). Model: 04 Shenr Valvc(s). ❑ Shear Valvc(s). Dia ons •Containment Floats (tad Chains . CI Dispenser Containment Floe, s Chain(,4), Chain . Dispenser I . MAIN DISPENSER 01 &2 Dispenser Ib; -- — M Dispens Coatninment Scdscrr(s). Model: 794380-208 ❑ Dispenser Containment Sensor(s), Model;,_ _ M Sheor Va vc(51 ❑ Shear Vnlve(s). Lftpeoser Cmtlalnmcnt Float s)and Chains . O Dis cnscr Containment Floats and Chains.D' SATELLITE k2 Dispenser ID;r•Containment Sensor(s), Madel: 794380-208 C3 DispenserContainmen(Sensor(s), Modcl:_,lve(sl. U Shear Valve(s). �.Coniainmcnt Floats and Chains . ❑ Dispenser Containment Floats and Chains , ^If the facility contains more tanks or dispensers,copy this form. Inclutle information for every tank and dispenser at the facility C. Certification -1 certify that the equipment Identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certiricatiun is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report(t'baek atl that(ytptP): ( )System set-tip O Alarm history report y 7 Technician Nante(print): Eric Molgaard, Signature: Tris ma(gaarcf Certiftcati n No.: ICC Tach 525020OUT License No.: 309105 Testing C patty Name:STOCKTON SERVICE STATION EQUIPMENT CO.INC, Phone No 209-464-8333 Site Addr s: 707 E. Roth Road, French Camp,CA Date of'resting/Servicing: May 17,2010 Page 1 of 4 03/01