COMPLIANCE INFO_2009-2015 - Laserfiche WebLink

Home Browse Search

4 . 0 0 PECEIVED MONITORING SYSTEM CERTIFICATIO For Use By All Jurisdictions Within the State of California FEg 4 20914 Authority Cited:Chapter 6.7, Health and Safety Code:Chapter 16. Division 3, Title 23,California Code of Regula tons This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be it system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner op l ? 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: LODI FOOD& LIQUOR County: SAN JOAQUIN Site Address: 1225 W LOCKFORD City: LODI Facility Contact Person: PAUL Contact Phone 209-333-1038 Make/Model of Monitoring System: INCON TS-1000 Date of Testing/Servicing: 1/11/2013 B. Inventory of Equipment Tested/Certified Tank ID: DSL 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: UL,S ❑ 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 bine Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Tank Overfill/I sigh-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specitc 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 I french 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: Dispenser ID: ❑ 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 1D: Dispenser ID: ❑,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 Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Check the appropriate boxes to indicate specific equipment inspected/serviced: 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 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): RHOME DESBIENS Signature: Certification 8293743702 License No.: 433159 Testing Company Name: B. Z. Service Station Maintenance Phone No.: (916) 371-2380 Site 1041 Triangle Court West Sacramento,CA 95605 Date of Testing/Servicing: 1/11/2013 Monitoring Certification Test Report I of 2