COMPLIANCE INFO 2009 - 2018 - Laserfiche WebLink

Home Browse Search

Appendix VI CINE (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at: http:Nwww.waterboards a MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California MAP rjrj 2017 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Title 23,California Code of Regu at' This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be PZ% �bN each monitoring system control panel by the technician who performs the work.A copy of this forth must be provided to the to �fkh(( MEN�/�L owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 d""I' U EPART A. General Information MENT Facility Name: FOOD&GAS VALERO Bldg.No.: Site Address: 2185 E FREMONT ST City: STOCKTON CA Zip: Facility Contact Person: JOGINDER Contact Phone No.: (-209)547-1700 Make/Model of Monitoring System: VEEDER ROOT TLS-350 Date of Testing/Servicing: 9-28-16 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID: 870CT TanklD: DSL N In-Tank Gauging Probe. Model: MAG 1 N In-Tank Gauging Probe. Model: MAG 1 N Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: SPLIT N Piping Sump/Trench Sensor(s). Model: 208 N Piping Sump/Trench Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Fill Sump Sensor(s). Model: 208 N Mechanical Line Leak Detector. Model: LD-2000 N Mechanical Line Leak Detector. Model: 99LD 2000 ❑ 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: 91 OCT Tank ID: N In-Tank Gauging Probe. Model: MAG 1 ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: SPLIT ❑ Annular Space or Vault Sensor. Model: N Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: N Fill Sump Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: N Mechanical Line Leak Detector. Model: FE PETRO ❑ 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: 1-2 Dispenser ID: 5-6 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3-4 Dispenser ID: 7-8 N Dispenser Containment Sensor(s). Model: 208 N Dispenser Containment Sensor(s). Model: 208 N Shear Valve(s). N Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: 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 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 at/that apply): N System set-up N Alarm history report Technician Name(print): David A.Winkler Signature: C Certification No.: 34975 License No: OTT 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 211 STREET GALT,CA 95632 Date of Testing/Servicing: 9-28-16 Monitoring System Certification Pagel of4 2/21/07