COMPLIANCE INFO 2008 - 2015 - Laserfiche WebLink

Home Browse Search

MONITWJNG SYSTEM CERTIFI&TION 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 L=./r. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of A. General Information OCT L $ [O1a Facility Name: Wine Country 76 Ell 0 Site Address: 1111 E. Kettleman Ln. City: Lodi,CA � � Facility Contact Person: Sonnie Contact Phone No.: (408) Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 10/6/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific cguiriment ins cted/serviced: Tank ID: T1: 87 Tank ID: T2: 91 ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390-420 ®Annular Space or Vault Sensor. Model: 794390-420 (split tank) ®Piping Sump/Trench Sensor(s). Model: PA02592000010 ®Piping Sump/Trench Sensor(s). Model: PA02592000010 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: VMI 99LD-2000 ®Mechanical Line Leak Detector. Model: FE Petro STP-MLD ❑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). Tank ID: T3: Diesel Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model: 794390.420 (splittank) ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: PA02592000010 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 10 Mechanical Line Leak Detector. Model: VMI 2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Madel: ❑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 ❑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 Floats)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 ❑Dispenser Containment Sensors). Model: ❑Dispenser Containment Sensor(s). Model: ®Shear Valve(s). ®Shear Valve(s). ®Dispenser Containment Float(s)and Cham(s). ®Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Seasons). 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). -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,I have also attached a copy of the report;(check all that apply): ® System set-up ®Alarm history report Technician Name(print): Guadalupe Sanchez Signature: Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services, Inc. Phone No.:(209) 845-8586 Testing Company Address: 521 Branding Iron St. Oakdale,CA 95361 Date of Testing/Servicing: 10/6/2010 Page 1 of 4 Rev(2/08)