INSTALL_2011 - Laserfiche WebLink

Home Browse Search

9255517899 Line 1 01 `24 a.m. 04-01-2011 2/7 GFrrgR-RYAN INC. GR Job # 10-058090 Appendix VI MONITORING SYSTEM CERTIFICATION 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 farm 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: Arco 6080 Bldg.No.: Site Address: 85 E Louise Ave City: Lathrop Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 311412011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspected/serviced: TanklD: 87-1 TanklD: 91 I% In-Tank Gauging Probe. Model: Mag Plus IX In-Tank Gauging Probe. Model: Mag Plus Ig Annular Space or Vault Sensor. Model: 794380-304 Ig Annular Space or Vault Sensor. Model: 794380-304 Piping Sump/Trench Sensor(s). Model: 794380,323 lK Piping Sump/Trench Sensor(s), Model: 794380.323 [S Fill Sump Sensor(s). Model: 794380-323 Eg Fill Sump Sensor(s), Model: 794380-323 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector Model: 848480 Electronic Line Leak Detector Model: 848480 1K Tank Overfill/High-Level Sensor. Model: Mag Plus Tank Overfill/High-Level Sensor. Model: Mag Plus ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment a and model in Section E on Page 2). TanklD: DSL TanklD: (g In-Tank Gauging Probe. Model: Mag Plus ❑ In-Tank Gauging Probe. Model: 1% Annular Space or Vault Sensor. Model: 794380.304 ❑ Annular Space or Vault Sensor. Model: Ig Piping Sump/Trench Sensor(s). Model: 794380-323 ❑ Piping Sump/Trench Sensor(s). Model: Ig Fill Sump Sensor(s). Model: 794380,323 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: IS Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: M Tank Overfill/High-Level Sensor. Model: Mag Plus ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pap-91. ❑ Other(specify equipment a and model in Section E on Page 2). Dispenser ID: Dispenser 1&2 Dispenser ID: Dispenser 3&4 IS Dispenser Containment Sensor(s). Model: 794380-323 1K Dispenser Containment Sensor(s). Model: 794380-323 IX Shear Valve(s). Ig Shear Valve(s). Cl Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser 5&6 Dispenser fD: Dispenser 7&8 Ig Dispenser Containment Sensor(s). Model: 794380.323 EK Dispenser Containment Sensor(s). Model: 794380-323 EX Shear Valve(s). ES Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). DispenserID: Dispenser 10: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Ffoat 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): Chris Bishop Signature: Certification No.: B36744 License.No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6747 Sierra Court Suite J, Dublin, Ca.94568 Date of Testing/Servicing: 3/14/2011 Monitoring System Certification Page 1 of 4 12107 1