COMPLIANCE INFO_2007-2018 - Laserfiche WebLink

Home Browse Search

Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at htto://wm.waterboards.ca.gov.} MONITORING SYSTEM CERTIFICATION For Use By Alt Jurisdictions Within the State of California ,Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of 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 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: _Bank of Stockton Bldg.No.: Site Address:1941 Lockheed Ct City: Stockton Zip:_95206 Facility Contact Person:Norman White Contact Phone No.:(209)-_483-0257 Make/Model of Monitoring System:Veeder-root TLS 350 Date of Testing/Servicing:_10 /_10 1 2016 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate s cific a ui ment In ected/serviced: Tank ID:Jet Fuel Tank ID: ❑ In-Tank Gauging Probe. Model:V/R-115 ❑ in-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model:V/R-409 ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model:V/R 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model:N/A u Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model:N/A ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model:N/A ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model:V/R ❑ Tank Overfill/High-Level Sensor. Model: o Other sp22!fy 2guipMent t0 and model in Section E on Pa e 2L ❑ Other(sp2c!y equipMent to and model in Section E on P e 2). Tank ID:_Other Transition Sumps 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:V/R 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Mods: ❑ Fill SumpSensor(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(specilecui ent t e and model In Section E on Pa 2. ❑ Other u' men/ a and model in Section E on P e 21. Dispenser ID:TOKHEIM PREMIER C Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s).(DPW) ❑ Shear Valve(s). ❑ DisE2nser Containment Fkta s and Chain(s). ❑ Dispenser Containment Flo2gsl and Chain(s). Dispenser ID:PERMIER Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). (DPW) ❑ Shear Valve(s). ❑ Dispenser Containment F!2atA and Chains. ❑ Dispenser Containment Floats and Chain(s). Dispenser ID:PREMIER Dispenser ID: E, Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). (DPW) ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats 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 equinment capable of generating such reports,i have also attached a copy of the report;(check all that apply): ❑System set-up ❑At istory report r Technician Name(print):JOE BARTHOLDI Signature: ^' / Certification No.: License.40,1001331 A- Testing Company Name:ELITE IV CONTRACTORS Phone No.:L209_)461-6337 Testing Company Address:2535 Wigwam Dr Stockton Ca_95205 Date of Testing/Servicing:_10/10/2016_ Monitoring System Certification Page 1 of 4 RECEIVED 12/07 NOV ' 6 2015 1 2/21/07 ENVIRONMENTAL HEALTH DEPARTMENT