COMPLIANCE INFO 2007 - 2009 - Laserfiche WebLink

Home Browse Search

JUN-29-2007 17:29 Service Station Systems 408 938 8888 P.02 MonitorhQ System Equipment 'ertification 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 eachmonitoring 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 system within 30 days of test date. A. General Information Facility Name: USA 68153 Bldg.No.: Site Address: 2448 W. Kettleman Ln. @ Lower Sacramento city: Lodi, CA zip: 95242-4123 Facility Contact Person: Sandy Contact Phone No__ (209) 369-3124 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 5129107 S. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment luspeeted/servieed. Tank ID•01-Regu Tank ID: 02-Plus ❑ In-Tank Gauging Probe. Model: VR 947390-107 p In-Tank Gauging Probe. Model: VR 847390-107 (3 Annular Space or Vault Sensor. Model: VR 724390-407 Qj Annular Space or Vault Sensor. Model: VR 7M9O-407 13 Piping Sump\Trench Scnsor(s), Model: VR 794390,209 Q( Piping Sump\Trench Sensor(s). Model: VR 794390.206 2 Fill Sump Sensor(s), Model: VR 794380.208 Q( Fill Sump Sensor(s). Model: VR 794380.208 ❑ Mechanical Line Leak Detector. Model: Hone ❑ Mechanical Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: None ❑ Electronic Line Leak Detector. Model: None ❑ Tank Overfill\High-Level Sensor, Model: None ❑ Tank Overfill\IIigh-Level Sensor. Modcl: None ❑ 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: Q3-Prem Tank IDS t3 In-Tank Gauging Probe. Model: VR 947390.107 p In-Tank Gauging Probe. Model: C[ Annular Space or Vault Sensor. Model:_VN 724320-407 ❑ Annular Space or Vault Sensor. Model: EX Piping Sump\Trench Sensor(s). Model VR 784390.206 ❑ Piping Sump\Trench Sensor(s). Model: M Fill Sump Sensor(s). Model: VR 704390.05 ❑ Fill Sump Sensor(s). Mvdcl; ❑ Mechanical Line Leak Detector. Model; None ❑ Mechanical Line Leak Detector, Model; ❑ Electronic Line Leal:Detector. Model; None ❑ Electronic Line Leak Detector. Model; ❑ Tank Overfill\High-Level Sensor. Model; None f1 Tank Overfill\High-Level Sensor. Model; ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify cquipmcnt type and model in Section E on Page 2). Dispenser ID: 01-02 Dispenser ID: 03.04 ❑ Dispenser Containmcnt Scnsor(s). Model: None 13 I)ispenscr Containment Sensor(s). Model: None ❑ Shear Valve(s), ❑ Shear Valve(s). 2[ Dispenser Containment Float(s)and Chain(s), IX Dispenser Containment Float(s)and Chain(s). Dispenser ID: 05.06 __ DispenserID. 07-08 ❑ Dispenser Containment Sensor(s). Model: None 13 Dispcnscr Containment Sensor(s). Model: None ❑ Shear Valve(s). p Shear Valve(s). 13 Dispcnscr Containment Float(s)and Chain(s). ll Dispenser Containment Float(s)and Chain(s). Dispenser 11% Dispenser ID• ❑ 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 Float(s)and Chain(s). •If the facility contains more tanks or dispensers,copy this term.Include information for every tank and dispenser at the facility C. Certification— I Certify that the equipment identified in this document was inspected/scrviced in accurdance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures`checklists)necessary to verity 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-, (check all that apply): ❑ System sct-up ❑ Alarm history report t Technician Name(print): Randy A Wilkerson Signature: Mfg. Cert.#.: A32404 ICC# 5258560-UT License.No.: 485184 Testing Company Name: Serv. Sta. SYS. Phone No.: (408)971-2445 Site Address: 2448 W. Kettleman Ln. @ Lower Sacramento Date of"1-esting/Servicing: 5/29/07