COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

0 0 'EIVEL 6ETi1fR-RYAN INC. GR Job # %-@ Appendix VI SEP 15 2015 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califd a1 o-r`RAcAi7 ENVIRONMENTAL 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: Arco 2093 Bldg. No.: Site Address: 3425 Tracy Blvd City: Tracy zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: VR TLS 350-R Date of Testing/Servicing: 9/8/2015 B. Inventory of Equipment Tested/Certified Cherk the anmmiadate hnies to indicate snacifir. enninment insnected/serviced: Tank ID: 1-87 Main Tank ID: 2-87 Aux ® In -Tank Gauging Probe. Model: 846390-107 [Sl In -Tank Gauging Probe. Model: 847390-107 ® Annular Space or Vault Sensor. Model: 794390-409 ® Annular Space or Vault Sensor. Model: 794390.409 ® Piping Sump / Trench Sensor(s). Model: 794380.208 LX1 Piping Sump / Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380.208 D Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: IM Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: 10 Tank Overfill / High -Level Sensor. Model: VR IM Tank Overfill / High -Level Sensor. Model: VR ❑ Other (specify ui ment type and model in Section E on Page 2). ❑ Other (specify ui ment type and model in Section E on Page 21. Tank ID: 3 -Siphon Tank ID: 4-91 0 In -Tank Gauging Probe. Model: 847390-107 ® In -Tank Gauging Probe, Model: 847390-107 ® Annular Space or Vault Sensor. Model: 794390409 ED Annular Space or Vault Sensor. Model: 794390.409 0 Piping Sump /Trench Sensor(s). Model: 794380-208 fat Piping Sump/ Trench Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector Model: 10 Electronic Line Leak Detector Model: 848480 111 Tank Overfill / High -Level Sensor. Model: VR ® Tank Overfill / High -Level Sensor. Model: VR ❑ Other (specify 2quipment type and model in Section E on Page 2). ❑ Other imecify equipment and model in Section E on Page 2). Dispenser ID: 1.2 Dispenser ID: 3-4 ® Dispenser Containment Sensor(s). Model: 794380-208 111 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). ED Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5 6 DispenserlD: 7-8 13 Dispenser Containment Sensor(s). Model: 794380-208 121 Dispenser Containment Sensor(s). Model: 794380-208 131 Shear Valve(s). EEI Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). DispenserID: DispenserlD: ❑ 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 Chains IT the Tacmry contains more tanKs or orspensers, copy tnrs Torm. mrauae mrormatron Tor every tanK ano dispenser at the Tacmry. 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 SanNIC018S Signature: Certification No.: B33787 License. No.: 220793 Testing Company Name: Gettler-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sierra Court Suite G., Dublin, CA 94568 Date of Testing/Servicing: 9/8/2015 Monitoring System Certification Page 1 of 4 12107