COMPLIANCE INFO 2007 - 2015 - Laserfiche WebLink

Home Browse Search

MONI1NORING SYSTEM CERTIFI'-ATION ox//r ®C 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 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. General Information Facility Name: Verizon Lodi Bldg.No. :Site Address: 2500 West Turner Road City: Lodi Zip: 95242 Facility Contact Person: Todd Harris Contact Phone No.: 972-729-5671 Make/Model of Monitoring System: Pnemercator 3000 Date of Testing/Servicing: 05/1412010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank 1D: Tank ID: 0 In-Tank Gauging Probe. Model: N-8-1 ❑ In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: ES 820 ❑ Annular Space or Vault Sensor. Model: Rl Piping Sump/Trench Sensor(s). Model: LS 600 ❑ Piping Sump/Trench 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 Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecifv equipment t e and model in Section E on Page 2). 1 ❑ Other(s ecifv e ui ment t e and model in Section E on Pare 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench 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 Overfill/High-Level Sensor. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: ❑ Other(s ecify equipment type and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on PaLe2). LMID: Dispenser ID: er Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: alve(s). ❑ Shear Valve(s), er Containment Floats and Chains . ❑ Dis enser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ 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). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s)_ Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,1 have also attached a copy of the report; (check all that apply): M System set-up El Alarm history report Technician Name(print): Keith Huston Signature: Certification No.: A 2 5 5 7 7 License.No.: 880430 Testing Company Name: EPIC Compliance Systems, LLC Phone No.: 888-700-EPIC Testing Company Address: 1001 Bayhill Dr, Suite 150 Date of Testing/Servicing: 05/14/2010 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidoes.org