COMPLIANCE INFO_1999-2010 - Laserfiche WebLink

Home Browse Search

MOM &RING SYSTEM CE I ATI For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7,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. If more than one monitoring system control panel is installed at the facility,a s arate certification or report must be prepared for each monitoring system control 1the teclulipian Avhe, orms the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must _ E a 0 4U, i�,11 t local agency regulating UST systems within 30 days of test date. Instructions are printed on the back of this page. A. General Information r§ ,a aae �{ �; P ,s T S..el egy'; 11N tr - ? ,_—:19 Facility Name: CAARNG STOCKTON AASF t i 1' �E j P 5` i r L bldg.No.: _ Site Address: 2000 Stimson Rd. City: Stockton Zip: 95206 Facility Contact Person: MSG Pica Contact Phone No.: (209)983-5348 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 8/412010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate spec equipment inspected/serviced Tank ID: 1)p-815K UST Tank ID: 2 jp8 20k AST ®In-Tank Gauging Probe. Model: Mag-7 ®In-Tank Gauging Probe. Model: Mag-7 ®Annular Space or Vault Sensor. Model: 420 0 Annular Space or Vault Sensor. Model: 420 ®Piping Sump/Trench Sensor(s). Model: 208 ❑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). 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/Trench 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: REEL UDC Dispenser ID: TRANS SUMP 10 Dispenser Containment Sensor(s). Model: 208 ®Dispenser Containment Sensor(s). Model: 208 ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ED:_ 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). 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). 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 Site Plan showing the layout of monitoring equipment. Fo any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): t s -up Alarm history report Technician Name(print): Hector Galindo Signature. C A23915 512835 Testing Company Name: Tank Team inc, Phone No.:(805) 658-0067 Site Address: 2745 Sherwin Ave#8 Ventura CA.93003 Date of Testing/Servicing: 8/4/2010 Page 1 of 3