COMPLIANCE INFO 1985 - 2004 - Laserfiche WebLink

Home Browse Search

MonitorinWystem EquipmenOWrtification 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 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: Shell 136143 Bldg.No.: Site Address: 4315 Waterloo Rd. @ Hwy. 99 City: Stockton, CA Zip: 95205 Facility Contact Person: Rachel Contact Phone No.: (209) 931-3674 Make/Model of Monitoring System: V/R Simplicity Date of Testing/Servicing: 05/07/02 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:01 -Regu Tank ID: 02-Prem 99 In-Tank Gauging Probe. Model: VR 847390.109 99 In-Tank Gauging Probe. Model: VR 847390.109 g9 Annular Space or Vault Sensor. Model: VR 794380.321 g9 Annular Space or Vault Sensor. Model: VR 794380.321 99 Piping Sump\Trench Sensor(s). Model: VR 794390-205 Q9 Piping Sump\Trench Sensor(s). Model: VR 794390-205 ❑ Fill Sump Sensor(s). Model: none ❑ Fill Sump Sensor(s). Model: None ❑ Mechanical Line Leak Detector. Model: None ❑ Mechanical Line Leak Detector. Model: None 29 Electronic Line Leak Detector. Model: VR 331198-001 99 Electronic Line Leak Detector. Model: VR 331196-001 ❑ Tank Overfill\High-Level Sensor. Model: None ❑ Tank Overfill\High-Level Sensor. Model: 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: Tank ID: ❑ In-Tank Gauging Probe. Model: ? ❑ In-Tank Gauging Probe. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Annular Space or Vault Sensor. Model: ? ❑ Piping Sump\Trench Sensor(s). Model: ? ❑ Piping Sump\Trench Sensor(s). Model: ? ❑ Fill Sump Sensor(s). Model: ? ❑ Fill Sump Sensor(s). Model: ? ❑ Mechanical Line Leak Detector. Model: ? ❑ 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: 01-02 Dispenser ID: 03-04 gl Dispenser Containment Sensor(s). Model: VR 794380322 Q9 Dispenser Containment Sensor(s). Model: VR 794380-322 29 Shear Valve(s). Q9 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- 05-06 Dispenser ID: 07-08 Q9 Dispenser Containment Sensor(s). Model: VR 794380.322 Q9 Dispenser Containment Sensor(s). Model: VR 794380.322 29 Shear Valve(s). 99 Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Q9 Dispenser Containment Sensor(s). Model: Q9 Dispenser Containment Sensor(s). Model: 99 Shear Valve(s). 29 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- 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'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; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print): SSS-Dave J. Signature: Original on file at SSS Certification No.: 341-32-5800 License.No.: 485184 Testing Company Name: Ser. Sta. Sys. Phone No.: (408) 971-2445 Site Address: 4315 Waterloo Rd. @ Hwy. 99 Date of Testing/Servicing: 05/07/02