COMPLIANCE INFO_2005 - 2009 - Laserfiche WebLink

Home Browse Search

MONITOING SYSTEM CERTACATION 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: MANTECA EXPRESS Bldg. No.: Site Address: 419 S.MAIN STREET City: MANTECA I Zip: 95336 Facility Contact Person: BOBBY MANGAT Contact Phone No.: (209)401-5292 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: APR 9, 2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: rTankID:91 Tank ID:87 Tank Gauging Probe. Model:MAG ®In-Tank Gauging Probe. Model:MAG nular Space or Vault Sensor. Model:420 ®Annular Space or Vault Sensor. Model:420 ping Sump/Trench Sensor(s). Model: 208 ®Piping Sump/Trench Sensor(s). Model:208 l Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model:LD 2000 ®Mechanical Line Leak Detector. Model:FXIV ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model:FLOAT ®Tank Overfill/High-Level Sensor. Model:FLOAT ❑Other(s2ecify equipment a and model in Section E on Pae 2). ❑Other(specify equipment a and model in Section E on Pae 2). Tank ID:DIESEL Tank ID: ®In-Tank Gauging Probe. Model:MAG ❑In-Tank Gauging Probe. Model: ®Annular Space or Vault Sensor. Model:420 ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model:208 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model:FXIV ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model: FLOAT ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment e and model in Section E on Page 2). ❑ Other(specifZ equipment a and model in Section E on Page 2). Dispenser ID: 1 -2 Dispenser ID:33=4 ❑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 Floats and Chain(s). Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats and Chains . ❑Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑ Dispenser Containment Floats 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 the 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): MIKE LAWRENCE Signature: Certification No:A26642 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VA CAVILLE, CA 95687 Date of Testing/Servicing: APR 9, 2008 Pagel of 3 Monitoring System Certification