COMPLIANCE INFO 2004 - 2008 - Laserfiche WebLink

Home Browse Search

AUG-24-2005 12:31 Service Station Systems 408 938 ee88 P.02 Monitor! System Equipment ertificatio7n For ZAe By All Jurisdictions Within The State of C.alffiornia Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16,Division 3, Title,23, Calij4brnia 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 mQancl 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 system within 30 days of test date. A. General Information Facility Name: Safeway 2600 Bldg.No.: _ Site Address: 1804 West 11Th. Street @ Corral Hallow City: Tracy, CA Zip: 95376- Facility Contact Person: � �.� - Contact Phone No.: (209)830.2950 Make/Model of Monitoring System:_VIR TLS-350 Date of Testing/Servicing: 8115/05 B. Inventory of Equipment Tested/Cerdfied Check the appropriate boxes to indicate specific equipment inspected/serviced: Tao ID- 1 15F&2 T tt ID• y Tank Gauging Probe. Model: k'' So- I C' -"tank Oauging Probe. Model: try 3 o-1'0V (?oo'A pular Space or Vault Sensor. Model: $ S+ ��+ alar Space or vault Sensor. Model: 79 RVI —j-1L-0 W� ng Sump\Trcnch Sensor(s). Modcl: " ' �/�op", g Sump\Trench Sensor(s). Model � O e I) @/Fill Sump Sensor(s). Model: Q�Fill Sump Sensor(s). Model: ' r ?. ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Lcak Detector, Model: &-015ectronic Line Leak Detector, Model: Jr9i y ectronie Linc Leak Detector. Model: l 7 q Tank Ovcrtill\High-Level Sensor. Model: ❑ Tank Overfill\High-Level Sensor. Model: Ll Other(specify equipment type and model in Section E on Page 2). p Other(specify equipment type and model in Section E on Page 2). Tank 1%, TankIDI -Tank Gauging Probe. Model: p in-Tank Gauging Probe. Model: GeA"�nnular Space or Vault Sensor. Model:�I 19 i �� El Annular Space or Vault Sensor. Model: [y-riping Sump\Trench Sensor(s), Model: (r_ p Piping Sump\Trench Sensor(s). Model: 2OTiil Sump Sensor(s). Model: 2.0 Cl Fill Sump Sensor(s). Model ❑ Mechanical Line Leak Detector. Model ❑ Mechanical Line Leak Detector. Model: [electronic line Lcak Detector. Model: Q Electronic Linc Leak Detector, Model: I� Ll 'Tank Overfill\tliglt-Level Sensor. Model: ___ p 'l'ank Overfill\I•Iigh-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 TD: Dislsenser IDA/ gDispcnscr Containment Sensor(s). Model: D' pctlscr Containment Sensor(s)- Model (tear valve(s).. ear Valvc(s). ❑ 1 N!i-penser ContainnMnt Float(s)find Chain(s). p Dispenser Containment Float(s)and Chain(s). Di• user ID-3 D' enser ID• �a ispcnser Contain crit Sensor(s). Model: 7 'penser Containment Sensor(s). Model [!r Shear Valve(s), f�Shcar Valve(s). Q Dispenser Containment float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). D��enser ID- Di enser ID;(! CIO Sensor(s'). Model: m Spensef Containent Sensor(s). Mode �ispensci'C /Shear Valve(s)• L+3 shear Valve(s)• Cl Dispenser Containment Float(s)and Chain(s), p Dispenser Containment Float(s)and Chain(s). •)f 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 manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary to verify that this information is correct and a Plot Plait showing the layout of monitoring qui tent. For any equip t capable of generatil such reports,t have also attached a copy of the; (check all that apply): ystem set-up arm hi. try repo Signature,Technician Name(print): SSS•Ran�yW __ g Certification Na.: (� -05- � ;E� License.No.: 485184 "testing Company Name' Ser. Sta. Sys. Phone No.: 408 971-2445 Site Address: 1804 West 11Th.Street - Corral Hallow Date of Testing/Servicing: 8115105 z