COMPLIANCE INFO_1996-2005 - Laserfiche WebLink

Home Browse Search

JAN-11-2005 21:12 SERVICE STATION SYSTEM 408 971 0135 P.02 Mon itri Syse ' ert �ica o , For Use By All Jurisdictions Within The State of California Authority Cited: Chapter 67. Health and Safety Code; Chapter 16, Division 3, Mle 23, California Code ofRegulatioro This form must be used to document testing and servicing of monitoring equipment.A_sc carate Certification or report must be r ared for each monitoring em 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 system within 30 days of test date. A- General Information Facility Name:Ripon Shell Bldg.No.: Site Address: 341 E. Main St.@ Hwy. 99 City: Ripon, CA Zip: 95366 Facility Contact Person: Mary Contact phone No.: (209)599-4464 MakeJModel of Monitoring System: V/R Simplicity �. Date of Testing/Servicing: 12/8/04 B. Inventory of Equipment Tested/Certified . Cheek the appropriate boxes to indicate spec equipment inspected/serviced: , Tank IID:01-Regu Tank ID; 02-Prem I © In-Tank Gauging robe. Model: VR 847390-1 os -"" 0 In-'rank Gauging Probe, Modck VR 847390,109 i Annular Space or Vault Sensor. Model: VR 74439.0302 Annular space or Vault Sensor, Model: VR 7943BO-302 Piping Sump 1 Trench Sensor(s). Model: VR 794380-208 Piping Sump 1 Tienell Sensor(s). Model, VR 794380,209 Fill Sump Sensor(s� Model: None 0 Fill Sump Sensor(s). Model: None (3 Mechanical Line Leak Detector. Model: None 0 Mechanical Line Leak Detector. Model: None 0 Electronic Line Leak Detector. Model: VR Serine 8484 0 Electronic Linc Leak Detector, Model: VR$66*4 94B4 0 Tank Overfill\High-Level Sensor. Model: None � 'tank Overfill 1 High-Level Sensor, Model: None 0 Other(specify equipment type and model in Section E on Page 2). © Other(speeify equipment type and model in Section E on Page 2� Tank ID: Tank m: 0 In-Tank Gauging Probe. Model: 7 C1 In-Tank auging Probe. Model: 7 Q Annular Space or Vault Sensor. Model: ? _ [3 Annular Space or Vault Sensor. Model: ? ® Piping Sump\Trench Sensor(s). Model: 7 A Piping Sump 1 Trench Sensor(s). Model:—? 0 Fill Sump Sensor(sA Model: ? O Fill Sump Sensor(s). Model: ? 0 Mechanical Line Leak Detector. Model: ? 0 Mechanical Line Leak Detector, Model: 7 0 Electronic Line Leak Detnvtor. Model: 7 __._.... s 0 Electronic Line Leak Dcw mr. Model: 7 0 Tank Overfill\High-Level Sensor. Model:__? 0 Teak Overfill\High-revel Sensor. Model: 7 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� Dispenser Ito; ispenser ID: 03.04 19 Dispenser Containment Sensor W. Model: VR 794380.321 Dispenser Containment Sensor(s} Model: VR 79439.0-321 Shear Valve(s). Shear Valve(a). Dispenser Containment Float(s)and Chain(s). p Dispenser Containment Float(s)and chain(s). l�ixperixer Containment Sensor(s} Model: VR>9439.0-321 16 Dispenser Containment Senior(x). Model: VR 794380421 Shear Valve(s). A Shear Valve(s). � 0 Dispenser Containment Float(s)and Chain(s), ® Diapenser Containment Float(s)and Chain(s). Dispenser ID: _ Dispenser 1D: 0 laisPenser(:onrainmcnt Scrutor(sj Mo ol: ? 0 Dispenser Contains:int •Dior s. i+dodel: ? (� Shear Valve(s). () Shear Valve(s). 0 Dispenser Containment Float(a)and Chain(s). Q Dispenser Containment Float(s)and Chain(s). °If the facility contains more tanks or dispensers,copy this form,include itlfomtation fbr every tank and dispenser at the facility C. Certification- r cetnbf'y that the equipmene identified in this document was inspected/serviced in accordance with the manufacturer's gul4etlaes. Attached to this Certification is information(®.g.manufactures,checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitortng'equipment, For any equipment capable of gencrating such reports,I have also attschcd a copy of the; (check all that apply)_ © System aetiup 0 Alarm history report Technician Name(print):SSS-Riakl) Signature, ° Certification No.: 00"5-1151 License.No.: 485184 Testing Company Name:Ser. Sta.Sys. Phone No.: (408)971-2445 Site Address: 341 E. Main St.@ Hwy:99 Date of Testing/Servicing: 1218/04