COMPLIANCE INFO_2007-2018 - Laserfiche WebLink

Home Browse Search

Aug. 6. 2018 9:29AM Donlee Pump Co No, 6377 P. 2 M0*01UNG SYSTEM CE T Y N .For Use By All Jurisdictions Within the State of California Authority Cited:-Chapter d 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. arm t)is-f A seas certification or reoort must be preaared for each monitoring systene cont Itnanel by the technician veno performs the work, A copy of this form must be provided to the tank system ownerloperator. The ownedoperator must submit a copy of this form to the local agency regulating LUST systems within 30 days of test date. A. General Information tl ,4 ' 1 Facility Name: Statewide Petroleum Bldg.No.- Site Address: 1700 i-Yosemite AVG. lP# Manteca Zip: Facility Contact person: Sunni �-0r LA,Nlomet.Phone No.: 408 230-8989 MakelModcl of Monitoring System: Veeder Root Date of Testing/Servicing: 8/2/2048 B. Inventory of Equipment' eSted/Certitied Check thea ro nate bores to indicates eeiGe t ul meal ins ected/servieeda: FTRnkID. Tank ID: Cl 1 ank aaaging Probe. Model: Tn-Tank Gauging Probe. Model: �hD�S-.._nular Space or Vault Sensor, Model: i9 Annular Space or Vault Sensor. Model: 20 ing Sump/Trench Sensor(s). Model: 4(Q, Zppj _ 9 Piping Sump/Trench Sensor(s). Model: Y(L z6 _ ❑l:ill Sump Seasor(s). Model: ❑fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: \IM® l.'1) �ooD _ 14 Mechanical Line Leak Detector. Model: L()Z — b bkc(ronle Line Leak Detector. Model: ❑Eleouonle Line Leak Detector, Model: 19 Tank Overfill/High-Level Sensor. Model: jEjQQ��e:$'' Tank Overfill/High-Level Sensor. Model: w e4' ❑Other(specify equipment type and model in Section nn Pb age 2). O Other(specify equipment type and model in Section •dh Page 2). Tank DD: 'Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: _ ❑Annular Spnee or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: _ ❑Piping Sump t Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fin Sump Sensor(s). Model: ❑Fill Sump Senwr(s). Model:_ ❑Mechanical Line Leak Detector. Model: Q Mechanical Line Leak Detector. Model: ❑Electronic)Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/Iligh-Level Sensor. Model: Q Tank Overfill l high-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser M! I` Z Dispenser M.- -q .Dispenser Containment Sensor(s). Model: g R Dispenser Containment Sensor(s). Model: V11 20% tg Shear Valve(s). 19shear Vaive(s). ❑Dispenser Containment Float(s)and Choin(s). ❑Dispenser Containment Float(s)and Chain(&). Dispenser ID: wtp Dispenser ID. '9 Dispenser Containment Sensor(s), Model: _ %W ZA$ 0 Dispenser Containment Scnsor(s), Model: 7-0—b _ M�Shcar Volve(s). hear'Valae(s). ®Dispenser Containment Floats)and Chaln(s), ❑Dispenser Containment Float(s)and Chain(s). Dispenser W: Dispenser lm: ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). Q Shear Valvc(s). ❑Dispenser Containment Float(s)and Chain($). Q Dispenser Containment Floats)and Chain($), *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 inspeeted/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$}te-DPiot]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(lint apply): KSystem set-up Alarm history lrepor Technician Name(print): Anthon Lelvss Signature, �--. Cettiftta i n I*1a.: 843482 License. 8224964 Testing Company Name: l]onlee Pump Company phone No.: 209 637-9396 Testing Company Address: 2825 Railroad Ave Cares CA,95307 Elate of Testing/Servicin& 812/2048 UN-036-U6 www,trnidoes.org Rev.01/17/08