COMPLIANCE INFO 2013 - 2017 - Laserfiche WebLink

Home Browse Search

9255517888 Line 08:48:20 01-20-2015 2117 r" CIET%,,-RYAN INC. G. -_,ob# 20-630005 Appendix VI MONITORING SYSTEM CERTIFICATION RECEIVED 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, Californid it-b9��bf' 15 Regulations ^ This form must be used to document testing and servicing of monitoring equipment.A separate certification or rep�t�nbs�bee ptij) Aa MAL each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank,systemi 1AFNT - - owner operator.�he owner/bpr3rator must submit a copy offfiis of rm to the locafagency regulating UST systems within 30-days of test--dat-- e. A. General information Facility Name: Arco SS 2186 Bldg.No.: Site Address: 3212 N.California Street City: Stockton zip: Facility Contact Person: Sarah Samuels Contact Phone No.: 360-371-8111 MakeiModel of Monitoring System: VR TLS 35OR Dale of Testing/Servicing: 1/1312015 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific equipment inspected/serviced: Tank ID: 87.1 Master Tank ID: 87-2 Siphon 10 In-Tank Gauging Probe. Model: 847390-109 0 In-Tank Gauging Probe. Model: 847390-109 ® Annular Space or Vault Sensor. Model: 794390-409 © Annular Space or Vault Sensor. Model: 794390409 ® Piping Sump/Trench Sensor(s). Model: 794380-208 © Piping Sump/Trench Sensor(s). Model: 794380-208 10 Fill Sump Sensor(s). Model: 794380-208 © Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: © Electronic Line Leak Detector Model: 8484.80 ❑ Electronic Line Leak Detector Model: Q Tank Overfill/High-Level Sensor. Model: VR © Tank Overfill High-Level Sensor. Model: VR ❑ Other(specify equipment a and model in Section E on Pa e 2)_ ❑ Other(specify equipment and model In Section E on Pa e 2). Tank ID; 91-3 TanklD: © In-Tank Gauging Probe. Model: 847390-109 ❑ In-Tank Gauging Probe. Model: © Annular Space or Vault Sensor. Model' 794390-409 ❑ Annular Space or Vault Sensor. Model• © Piping Sump!Trench Sensor(s). Model: 794380.208 ❑ Piping Sump/Trench Sensor(s). Model: © Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: © Electronic Line Leak Detector Model: 8484.80 ❑ Electronic Line Leak Detector Model: ® Tank Overfill!High-Level Sensor. Model: VR ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section Eon Pa 2). ❑ Other(specify equipment and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: 3.4 ® Dispenser Containment Sensor(s). Model: 794380323 © Dispenser Containment Sensor(s). Model: 794380.323 10 Shear Valve(s). © Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats and Chaln s. DispenserlD: 5-6 D ispenser ID: 7-8 ® Dispenser Containment Sensor(s), Model: 794380-323 Containment Sensor(s). Model: 794380-323 Shear Valve(s). hearValve(s). ❑ Dis enser Containment Floats and Chains. Dispenser Containment Floats and Chain(s). DispenserlD: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s), ❑ Dispenser Containment Floats 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): p System set-up M Alarm history report Technician Name(print): Chris Sar laolas Signature: Certification No.: B33787 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sierra Court Suite G.,Dublin,CA 94568 Date of Testing/Servicing: 1/13/2015 Monitoring System Certification Page 1 of 4 12107 1