COMPLIANCE INFO_2004-2012 - Laserfiche WebLink

Home Browse Search

0811412012 20:38 (209)465-4988 MaryAnn Henderson Page 3/19 MONARING SYSTEM CL'RTINCAIRON For Use By All Jw&dkdom Within the Swe of Caftjbrwa Authority Cited Chapter 6 7,Health and Safety Code, Chapter 16,Division 3,Title 23,California Code ofRegidations This form must be used to document testing and servicing of monitoring equipment A=v=gWftation or MM mug be Rn=d for each a system q=aLVjW by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The ownffloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Nazi: QUICK SHOP VALERO Bldg.No.: Site Address: 1001 E YOSEMITE City. MANTECA Zip: 95M Facility Contact Person. MGR Contact Phone No.:(209)825-4569 Make/Model of Monitoring System:GILBARCO EMC Date of Testing/Servicing:l 1 B. Inventory of Equipment Tested/Certified Check the aptimmiatt boxes to indicate specific equipment ins serviced: Tank ED: UNLEADED 87 Tank 111): PREMIUM 91 0 In-Tank Gauging Probe. Model: [I In-Tank Gouging Probe. Model: 0 Annular Space or Vault Sensor. Model: 407 Annular Spam or Vault Sensor. Model: 407 0 Piping Sump/Trench Seasor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 El Fill Sump Sensor(sl Model: 171 Fill Sump sensor(s). Model: Mechanical I=Leak Detemr. Model: LD2000 IR Mechanical I=Leak Detector. Model: L02000 ❑Sectionic I=Leak Detector. Model: DElectronic Line Leak Detector. Model: Tank Overfill I High-Level Sensor. Model: FLAPPER 0 Tank Overfill/High-Level Sensor. Model: FLAPPER Ocither(specify equipment 4W and model in Section E on Page 2). F-1 Other(specify equipment type and model in Section E on Page 2), Tank ID: DIESEL Tank ED: 0 In-Tank Gauging Probe Model: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 408 0 Annular Space or Vault Sensor. Model; 9 Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 1 [3Fill Sump Sensor(s). Model: Ej Fill Sump Sensor(s). Model: Mechanical Line Leak Detector, Mode LD2000 13 Mechanical Line Leak Detector. Model: [3131ectmic Line Lcak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill I High-Level Sensor. Model: FLAPPER 0 Tank Overtill/High-Level Sam. Model: 0 Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment t)w and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID: 314 [I Dispenser Containment Smor(s). Model: r7l Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). she"Valve(s)_ 19 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ED: 516 Dispenser n): 7/8 n Dispenser Contaftnerit Swsor(s} Model: [I Dispenser Containment Sensor(s� Model: Shear Valve(s). Shear Valve(s). Dispenser Containment FUags)and Chain(s). Dispenser Containment Flool(s)and Chain(s), Dispenser ID: Dispenser ID: [I Dispenser Containment Smsor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s) Shear Valve(s} Doenser Contairinicrit Floats)and Chafti(s} Dispenser Containment Float(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. CertifiCati011k - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'go 'nes. Attached to this Certification is information(eg manufacturers'cliecUbb)necessary to verify that this informadog 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 alt that q#y): 0 Syste 0 Alarm histmw report Technician Name(print): Charles Ferrucci Signature:. Certification No.: B37513 License.No.: 962520 Testing Company Name: Smice Station Testing,Inc. Phone No.:(209) 4656577 Testing Company Address: PO Box 31465 Stockton,Ca Date of Testing/Servicing, 112412012 Page I of 3 Rev(2/08)