COMPLIANCE INFO_2010-2012 - Laserfiche WebLink

Home Browse Search

Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httpJ/www.wabrbmrde.ce.gov) Monitoring System Certification For Use By AN JudadkOm VAU# l the State of Celifamie Authority Cited. Chapter 6.7 Neatft and Safety Code; Chapter 16, Division A Me 23, CoNbaga Code of RegulMlions This form must be used to document tasting and of monitoring equipment A se nate oartillcaliform must be oon or report must be prepared for each �/ parato must subrrdt system control a ccappy of tel by the � form ton t perf� agency regulating work A USTopy �syssttems within 30 days of Net date. ed to the tank system atoned .The A. General Information F : Pacific Bell T one Co. dba AT&T California GEO PAR # UE042 Address: 345 N. SAN JOAQUIN City. STOCKTON Zi :95202 Facift Contact Perm: Connie Mitchell Contact Phone No: 209598-5155 Make/Model of Moriftodag S ern: Veeder-Root TLS -350 Servioe Data: 01/07/2011 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment InspectafterAced: Tarn ID: UE0420001 Tank ID: ❑ In -Tank Gauging Probe Modet ❑ In -Tank Gauging Probe mel; ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model; ® Piping Snare / Trench Sensor(s) Model: 794380-208 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fir Sump Sensor(s) Model: ❑ F0 Snapp Sensors) feel: ❑ Mechanical L&e Look Detector Model: ❑ Mac hanical Una Leak Detector Modet ❑ Electronic Line Leads Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High Level Sensor Model: ❑ Tank OverM / High Level Sensor Model: ❑ Other (Specify equipment type and model to Section E on Page 2) ❑ Other (Specify equipment type and model in Section E on Page 2) Tank ID: Tank ID: ❑ In -Tank Gauping Probe Model: ❑ In -Tank Gauging Probe Mom: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor MSI: ❑ Piping Sump / Trench Senso s) Model: ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fa Sump Sensor(s) Model: ❑ Fri Sump Sa,sor(s) Model: ❑ Mechanical Urn Leak Detector Model; ❑ mechanical Une Leak Detector Model: ❑ Bectrafic Une Leek Detector Mom: ❑ Elacbmic i trne Leek Detector Model: ❑ Tank Overfill / High Level Sensor Model: ❑ Tank Overfill / High Leval Sensor Model: ❑ Dow (Specify equipinent type and model M Section E on Pape 2) ❑ Other (Specify equipment type and model In Section E an Page 2) Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispensw Containment Sensor(s) Model: ❑ Shear Velve(s) ❑ Sheer Velve(s) ❑ Dispenser Contoinmant Flost(s) and Chain(s) ❑ Dispenser Containment Roat(s) and Chain(s) Disp2nserID: DispenserID: ❑ Dispenser Contairtment Sensor(s) Model: O Dispenser Containment Senso4s) Model: ❑ Shea va%*S) ❑ Shy Va"s) ❑ Dispenser Cant inme t Floats) and Chatn(s) ❑ Dispenser Containment Float(s) and Chaln(s) Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shea Vak*s) ❑ Shear Valves) ❑ Dispenser Containment Float(s) and Chak*) ❑ Dispenser Containment Floats) and Chakn(s) • if the factey contains more tanks or dispensers. copy tins form. Include Information tar every tank and diaper*" at the tae ft. C. Certification. I certilly that the equipment identified M this docurnent was Inapectedleeirviced M accordarkes wink the manufacturers' guidelines. Attached to this Cortlftcation Is (nfonnidon (e.. ma rers' checidlsts) to verify gnat this iMonnidlon is coact and a Plot Plan shows the layout of monitoring egad merit. For arty equipment capable of generating suchroports, I heirs also a Copy OT the report; tCiWCk an that appy,: Monitoring System Cn Mcation Page 1 of 4 12/07 =1107