COMPLIANCE INFO_2003-2015 - Laserfiche WebLink

Home Browse Search

MONITOUNG SYSTEM CERTIFROTION For Use By All Jurisdictions Within the State of California AuthorityCite& Chapter 6 7,Health and Safety Code;Chapter 16, Division 3, Title 23, California Code op�i6opgtjgjon This form must be used to document testing and servicing of monitoring equipment. A separate certification or report WA161 `"�JlJigiGh"i monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the 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: Super Stop Market Bldg.No.: Site Address: 290 N. Main City: Manteca Zip: 95336 Facility Contact Person: Kiran Jeet Contact Phone No.: (209) 239-4475 Make/Model of Monitoring System: EMC Date of Testing/Servicing: 3/2512008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sMific Squipment inspected/serviced. Tank ID: T-1 91 Tank w: T-2 Diesel 19 In-Tank Gauging Probe. Model: 847390-207 [R In-Tank Gauging Probe. Model: 847390-207 0 Annular Space or Vault Sensor. Model: 794390-420 10 Annular Space or Vault Sensor. Model: 794390A20 0 Piping Sump/Trench Sensor(s). Model: 0794380-208 0 Piping Sump/Trench Sensor(s). Model: 0794380-208 El Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ' ED Mechanical Line Leak Detector. Model: STP-MLD Mechanical Line Leak Detector. Model: 105989471 F-1 Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank ID: T-3 87 Tank ID: In-Tank Gauging Probe. Model: 847390-207 ❑In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor'. Model: 794390-420 El Annular Space or Vault Sensor. Model: 10 Piping Sump/Trench Sensor(s). Model: 0794380-208 0 Piping Sump/Trench Sensor(s). Model: n Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: ED Mechanical Line Leak Detector. Model: LD-2200 ❑Mechanical Line Leak Detector. Model I n Electronic Line Leak Detector. Model: El Electronic Line ixg' Detector' Model: El Tank Overfill/High-Level Sensor. Model: El Tank Overfill/'High'-Level Sensor. Model: El Other(specify equip ment 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 ED: 3/4 El 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). Dispenser ED: 5/6 Dispenser ID: 7/8 ❑Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s)' Model: Shear Valve(s). 0 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). [D Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9110 Dispenser ID:-11/12 n Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: [D Shear Valve(s). Shear Valve(s). M 0 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 eq u' capable of generating such reports,I have also xn attached a copy of the report;(check all that apply): System set-up Alarm history-rport Technician Name(print): GavinWilflams Signature: Certification No.: WIKT2074 License.No.: 856771 Testing Company Name: HMC-Henderson Maint Co Phone No.:(209) 467-7573 Site Address: PO Box 31325,Stoickton,CA 95213 Date of Testing/Servicing: 3/25/2008 Page 1 of 3