COMPLIANCE INFO 2001 - 2006 - Laserfiche WebLink

Home Browse Search

P,7bn/p)3/39y MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Calitc,....a 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. If more than one monitoring system control panel is installed at the facility,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: BEACON#67080 City: LODI CA Zip: 95242 Site Address: 2448 W. KETTLEMAN LN Contact Phone No:369-3124 Facility Contact Person: MANAGER Date of Testing/Service: 09/04/2002 Make/Model of Monitoring System: GBCO EMC Work Order Number: 2223477 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: REGULAR Tank ID: PLUS X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe, Model. MAG X Annular Space or Vault Sensor Model: VR 407 21 Annular Space or Vault Sensor. Model VR 407 X Piping Sump/Trench Sensor(s) Model: VR 208 VR 208 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: VR 208 VR 208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: RJ FX1 V RJ FX1 V 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(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: SUPREME Tank ID: X In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: VR 407 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: VR 208 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sensor(s). Model: VR 208 Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: RJ FX1 V 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(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). Dispenser : 112 Dispenser ID: 7/8 Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). X Shear Valve(s) ❑X Dispenser Containment Float(s)and Chain(s). X Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3/4 Dispenser ID: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: X Shear Valve(s). Shear Valve(s). X Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). X 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): System set-up report; El Alarm history report X❑ 14--, PRINTED NAME:KEVIN MATLOCK SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01