COMPLIANCE INFO 2005 - 2009 - Laserfiche WebLink

Home Browse Search

MONIT ING SYSTEM CFAUIFICATION ' "rI',4//Jurisdictions Within the ��,ac u/C'uti/u I uthorin•Cited: Chapter h. Heult nd.4ct/ehv Code. Chanter !h, Un . ; lir .t Tid,,Z,,California Code of Regulations I his limn must be used to document testing and seri icing of monitoring equipment. .\ cpar is certification or report must he prepared lire each monitoring >\ m_control panel by the technician who perfitmms the work. A copy of this form must he prof ided to the tank system ov%ner operator. the os�ner or . Oor mwo suhmil a cup} ol'this form to the local agencs regulating, I ,I ss stems%%ithin 30 dans of lest date. A. (.cncral Information Facile. Name: _SHELLBldg. No.: _ Site Address: 4315 E.WATERLOO RD _ City: STOCKTON Zip: 95205 Facilit- Contact Person: BILL Contact Phone No.: (209) 931-3674 Maker Model of Monitoring System: TLS 350 Date of TestingrServicing: 5/612009 B. Inn entor% of Equipment Tested/Certified (heck the approeriate hoses to indicate sEccific a ui ment in,iccted.seniced. Tank ID: 87 7Fank ID: 91 ®In-tank(,atwirm Probe Modcl MAGA ©III-I ank Gauging Probe Model. MAG-1 ®Annular~pace or %ault'Sensor Model 001 — ®Annular Npacc or Vault Sensor %lodel 001 ®Piping Nunrp I rcnch Scnsor(s) Modcl 208 ®Piping Sump' french Scnsor(s) Model323 ®Dill Surnp Semanst Madel 208 ®Dill Sump Sensarls) Model. 208 ❑ Mechanical lite I cak Defector Model ❑Mechanical Lyne Leak Detector Model ®I !echoing Linc Leak fetector Model PLLD ® 1 lectronic I me Leak Detector Madel PLLD i ❑ I ank(INerfill'I ligh-I.escl Ncnsor Model ❑ Dank Overfill Iligh-1v%cl'Scnsot Model. ®()(hcr ospecify equipment type and model III Section F on Page 2) ®Other(specify equipment v pe and model in Section F on Page 2) Tank ID: Tank ID: ❑In-I ank(iauoine Probe Model ❑In-1 ank Gau um I'rohc Model ❑Annular tipacc or Vault Sensor Model ❑Annular Spacc or Vaull Ncnsor Model ❑Pipnts'Sump french Sensors) Model ❑Piping 5urnp I reach wrim)os) \Madel. ❑I III Nump Sensor!+) Model ❑U IIt Sump Sensorls) Model ❑Mechanical Line Leak Detector Model ❑Mechanical I me leak Detector Model. ❑I'lectronic Linc I cak Detector. Model Cl I lectronic Line Leak Ietector Model ❑ lank Ocertill I Itgh-Level Sensor Model ❑ I ank I hcrtill I hgh-Level Sensor Model ❑Other(%peat}equipment type and model in Section E on Page 2) ❑Other(specth equipment type and model in Section F:on Page 21 Dispenser ID: 1-2 Dispenser ID: 3-4 ® I)ispenserC'ontainment Sensorfs) Model 208 ®I)rspenser(-ontainment Semons) Model 208 ®Shear Valvas) ®Shear Valves) ❑Disprn,er Containment Floaus)and C'haims) ❑Dispenser Containment Float(s)and Cham(s) 7ffipeser ID: 5-6 Dispenser ID: 7-8 nscr(ontanrment Scrtsortsi. Model 208 ® IhspenscrC'ontainment Scnsurls) Model 208 ®Nhcar Vahe(s) ®Shear Val%c(s) ❑ Dispenser("ontamment 1(oalls)and(hanes) ❑D)rspenscr Containment I loat(s)and Chain(s). Dispenser ID: Dispenser ID: ❑DhspenserContainment Sen,(w,I Model ❑ I)spcnscr(ontamment Sensor(,,) Model ❑Shear Val%c(si ❑Nhatr Vahci%) l ❑ Dispenser( ,uaamment Floatls)and Chain(s). ❑ I)Ispcnser Containment Float(s)and C'hain(s). •ll'the t'aciliu contains more tanks or dispenwrs.copy this form. Include intbrmation tier ever\ tank and dispenser at the facilirc C. Certification - 1 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. N'or any equipment capabl f generating such reports, I have also attached a copy of the report:(check all that npplr): ❑ System set-up ❑ Alarm tory report Technician Name(print): Heath A McEver Signature: Certification No.: A27562 License. No.: 5236756-UT Testing Compam Name: SST-Service Station Testing Phone No.:(209) 465-5577 'Testing Company Address: PO Box 31465 Date of Testing:'Servicing: Page 1 of 3 Rev(2:'08)