COMPLIANCE INFO_2014 - 2018 - Laserfiche WebLink

Home Browse Search

rh"ECEIVED Appendix VI MONITORING SYSTEM CERTIFICATION OCT 2 3 2014 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 ReNaulla�Qf>�AL HEALTH This form must be used to document testing and servicing of monitoring equipment. A separate certification or reports e r p e� a r IV each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tan(RTM ENT owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days esf ate. A. General Information Facility Name: Site Address: Facility Contact Person: FLAG CITY CHEVRON 6421 CAPITAL City: Make/Model of Monitoring System: VEEDER ROOT TLS 350 Bldg. No.: Zip: 96242 Contact Phone No.: (209) 334-0976 B Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Servicing: 9/24/2014 Tank ID: 87 Tank ID: 91 Z In -Tank Gauging Probe. Model: MAG 1 N In -Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 409 Z Annular Space or Vault Sensor. Model: 409 Z Piping Sump / Trench Sensor(s). Model: 208 N Piping Sump / Trench Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 Z Mechanical Line Leak Detector. Model: PE PETRO N Mechanical Line Leak Detector. Model: PETRO ❑ 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: DIE Tank ID: 87 SYPON Z In -Tank Gauging Probe, Model: MAG 1 Z In -Tank Gauging Probe. Model: MAG 1 Z Annular Space or Vault Sensor. Model: 409 Z Annular Space or Vault Sensor. Model: 409 Z Piping Sump / Trench Sensor(s). Model: 208 Z Piping Sump / Trench Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 Z Fill Sump Sensor(s). Model: 208 Z Mechanical Line Leak Detector. Model: LD 2000 Z Mechanical Line Leak Detector. Model: PE PETRO ❑ Electronic Line Leak Detector. Model: Z 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). Dispenser ID: 1-2 Dispenser ID. 3-4 Z Dispenser Containment Sensor(s). Model: 208 Z Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 ® Dispenser Containment Z Dispenser Containment Sensor(s). Model: 208 Sensor(s). Model: 208 N 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): Z System set-up Z Alarm history report Technician Name (print): FELIX RAMIREZ Signature: Certification No.: 834976 License No: 5273934 -UT 08-1740 OTTL Testing Company Name: AFFORDA-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2 STREET GALT CA 95632 Date of Testing/Servicing: 09-24-14 Monitoring System Certification Page 1 of 4 2/21/07