COMPLIANCE INFO_1994-2006 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFIARON For Use By All Jurisdictions Within the State of California 4 Authority Cited:-Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations I 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: AT&T/SBC GEO PAR# UE-042 CLLC Coder SKTNCA01 Site Address: 345 N.SAN JOAQUIN City: STOCKTON Zip: Facility Contact Person: TOM WILLIAMS Contact Phone No.: 209-466-1010 Make/Model of Monitoring System: VEEDER-ROOT TLS-350 PLUS bate of Testing/Service: 7/19/06 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 1052 Tank ID: ®In-Tank Gauging Probe: Model: 847390-109 ❑In-Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794390-420 []Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor(s): Model: 794380-352 ❑Piping Sump/Trench Sensor(s): Model: ®Fill Sump Sensor(s): Model: 794380-352 ❑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: 790991-001 ❑Tank Overfill/High-level Sensor: Model: ®Other,S2ecify a ui .type and model in Section E on Page 2 ❑Other,Specify a ui .ty2e 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 equip.t e and model in Section E on Pa e 2 ❑Other,Spec a ui .t e and model in Section E on Page 2 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) ❑Dis eraser 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) ❑Dis enser 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). ❑Dis enser Containment Float(s)and Chain(s) ❑Dis enser Containment Hoat(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 equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System set-un _ "rm-hi report Technician Name(Print): MICHAEL L.STRAWN,II Signature: Certification No.: 006-05-3018 License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222