COMPLIANCE INFO 2006 - 2011 - Laserfiche WebLink

Home Browse Search

MON NG SYSTEM CERTIF#0I0N For se 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 1 This form must be used to document testing and servicing of monitorin a ui ment. A se arate g 9 P e krepared for each monitoring system control panel by the technician who performs the work. A copy of this form mu` be J 1W�, i t tem owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems wi ays of test date. A. General Information Vim e 1 2009 Facility Name: MAIN STREET ARCO �WVIRONMENI IM o.: Site Address: 1100 S. Main Street City: Manteca PFRMITIOM ip: 95336 r Facility Contact Person: Jesse Chadda Contact Phone No.: (209) 825-6784 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 3/30/2009 B. Inventory of Equipment Tested/Certified Check the apgroeriate boxes to indicate specific equipment inspected/serviced: Tank ID: T1: 87 Unleaded Tank ID: T2: 91 Premium ®In-Tank Gauging Probe. Model: 847390-109 ®In-Tank Gauging Probe. Model: 847390-109 ®Annular Space or Vault Sensor. Model: 794390-409 ®Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump/Trench Sensor(s). Model: 794390-323 ®Piping Sump/Trench Sensor(s). Model: 794390-323 ®Fill Sump Sensor(s). Model: 794390-323 ®Fill Sump Sensor(s). Model: 794390-323 ®Mechanical Line Leak Detector. Model: LD 2000 ®Mechanical Line Leak Detector. Model: STP-MLD ❑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: T3: 89 Plus Tank ID: ®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: 794390-323 ❑Piping Sump/Trench Sensor(s). Model: ®Fill Sump Sensor(s). Model: 794390-323 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: STP-MLD ❑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 ID: 1 &6 Dispenser ID: 2&5 E Dispenser Containment Sensor(s). Model: 794390-323 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3 &4 Dispenser ID: 7& 12 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 8& 11 Dispenser ID: 9& 10 21 Dispenser Containment Sensor(s). Model: 794390-323 ®Dispenser Containment Sensor(s). Model: 794390-323 ®Shear Valve(s). ®Shear Valvc(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): ® System set-up ® Alarm history report Technician Name(print): Guadalupe Sanchez Signature: __7i� Certification No.: A30138 License.No.: 883706 Testing Company Name: Reliable Petroleum Services Inc. Phone No.: (209) 845-8586 Testing Company Address: 521 Branding Iron St. Oakdale Ca. 95361 Date of Testing/Servicing: 3/30/2009 Page 1 of 4 Rev(2/08)