COMPLIANCE INFO_2010-2012 - Laserfiche WebLink

Home Browse Search

11 0 RECEIVEI Appendix Vi (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.wateftards. ) 0 5 2011 Monitoring System Certification For Use By Ali Jurisdictions Within the State of Califomia EWRONMENTAL H Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of R&guPMrrj8EFMCM 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: Pacific Bell Telephone Co. dba AT&T California GEO PAR # UE042 Address: 345 N. SAN JOAQUIN Ci!y: STOCKTON Zi : 95202 Facility Contact Person: Connie Mitchell Contact Phone No: 209-598-5155 Make/Model of Monitorin System: Veeder Root TLS 350 Service Date: 05/13/2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate speefflc equipment inspectedisetviced: Tank iD- UE0420001 _ Tank ID: Certification No: 8365632 ® 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:794380.208 ❑ Piping Sump / Trench Sensor(s) Model; ® Fill Sump Sensor(s) Mode1:794380-208 ❑ 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:Other ❑ 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) MSI: ❑ Piping Sump / Trench Sensors) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensors) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronlc 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: 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 Valves) ❑ 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 Valves) [] Shear Valves) L ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) If the facility contains more tanks or dispensers, copy this forth. Include information for every tank and dispenser at the facility. C. Certification- I certify that the equipment identified In this document was inspectediserviced 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): ® Sys set-up® R41T history report CTechnician Name (Print): Victor Guerrero _ Si nature: Certification No: 8365632 License No: 588098 Testing Company/ Name: TAIT ENVIRONMENTAL SERVICESPhone No: 1714) 560-8222 r Testing Company Address: 2131 South Dupont Drive Anaheim CA 92806 Date of Testin /Servicin : 05/13/2010 Monitoring System Certification Page 1 of 4 12/07 1 W')I M