COMPLIANCE INFO_2004-2012 - Laserfiche WebLink

Home Browse Search

� tin Appendix VI Address Corrected Results (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at MONITORING SYSTEM CERTIFICATION 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 TMCEIVED Regulations 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 syg(�gy 201 owner/operator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test d�f� A. Generallnformplion Facility Name: "ado Bldg.No.: — RONMENTAL HEALTH Site Address: 1001100ftE SE'k"`*t cry: Manteca zip: 95336 PERMIVSERVIGLd, Facility Contact Person: Contact Phone No.:( Make/Model of Monitoring System:EMC Date of Testing/Servicing:__{__J_ 1-28-11 B. Inventory of Equipment Tested/Certified Check the approuriarte boxes to W91s9L:c=eaLdornant insi ectecilservooed* Tank ID Tank ID: x In-Tank Gauging Probe. Model: K In Tank Gauging Probe. Model: x Annular Space or Vault Sensor. Model: K Annular Space or Vault Sensor. Model: x Piping Sump/Trench Sensor(s). Model:208 x Piping Sum/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fig Sump Sensor(s). Model: K Mechanical Line Leak Detector. Modei: x 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: Othersoecifiv:suipment type and model in Section E on Pa 2). Others equipment tvDa and model in Section E on Pao e 21. Tank ID: Ldiesei Tank LD: x in-Tank Gouging Probe. Model: In Tank Gauging Probe. Model: Annular Space orVault Sensor. Model: Annular Space or Vaug Sensor. Model: x Piping Sump!Trench Sensor(s). Model: Piping Sump!Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: x Mechanical Line Leak Detector. Model: - Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill f High-Level Sensor. Model: Tank Overfill f High-Level Sensor. Model: Other a 0 Went type and model in Section E on Page 21. Other 2=epuioment type and model in Section E on Paris Z. MspenserID: Dispenser 10: 4/4_ Dispenser Containment Sensor(s). Model: Dispenaer Containment Sensor(s). Model: x ShearValve(s). x ShearValve(s). x OispenserContainment Float and Chain(s). x Oispapser0offtaftnuent Floe and Chain(s). Dispenser ID: 010 DlspeimT 10: 1/0 Dispenser Containment Sensor(s). Model: Dispenser ContainmentSerksor(s). Model: x Shear Valve(s). x Shear Valve(s). x DispenserContamment Floats and Chains. x D' ser Containment Floats and Chain . tlispenserlD: Dispenser ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dis ser Cb inment Floats and Chan s U22nserCortainmeM Float(al and Chain s. -if the fac ty con•tain$more tanks or dispersers,copy this form. Include Information forever.,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 aff that appty): System set-up Alann history report Technician Name(print).Gavin Williams Signature: �1•/�'��~� Certification No.: ICC# 8016288-UT License.No.:CSLB# 856711 Testing company Name:Henderson Maintenance Company Phone No.: 219) 467-7573 Testing Company Address:PO Box 31325 Stockton,CA 95213 Data of Testing/SeNicing:`t_ r 1-28"11 Monitoring System Certification Page 1 of 4 12/07 1 2/21/07