Laserfiche WebLink
MONITORING SYSTEM CERTIFICATI W For Use By All Jurisdictions Within the State of California f Authority Cited:Chapter 6.7,Health and Safety Code,Chapter 16,Division 3,Title 23, Cali o n ahons <br /> This form must be used to document testing and servicing of monitoring equipment.Amparate certification or EmQdW 10 fira7"for each <br /> monitoring Wt-em contra]tranel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. <br /> The owner/operator must submit a copy of this form to the local agency regulating LIST systems within 30 days oftryd NE NZw <br /> A. General Information HEALTH 11EPARTMENT <br /> Facility Name: BANK OF STOCKTON Bldg.No.: Hanger#3 <br /> Site Address: 1941 LOCKHEED CT. City: STOCKTON Zip: <br /> Facility Contact Person: NORMAN WHITE Contact Phone No.: (209)483-0257 <br /> Make/Model of Monitoring System: VEEDER-ROOT TLS-350 Date of Testing/Servicing: 10/20/2015 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the a ro .ate boxes to indicatespecific Equigment Ins ed/serviced: <br /> Tank ID: JET FUEL Tank ID: <br /> ❑in Tank Gauging Probe. Model: ❑in-Tank Gauging Probe. Model: <br /> ®Annular Space or Vault Sensor. Model: VR 794390-408 ®Annular Space or Vault Sensor. Model: <br /> ®Piping Sump/Trench Sensor(s), Model: VR 79MO-208 ❑Piping Sump/Trench Sensw(s). Model: <br /> ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: <br /> ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: <br /> ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: <br /> ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: <br /> ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). <br /> Tank ID: OTHER-TRANSITION SUMP Tank ID: <br /> ❑in-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: <br /> ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: <br /> ®Piping Sump/Trench Sensor(s). Model: VR 794380-208 ❑Piping Sump/Trench Sensor(s). Model: <br /> ❑Fill Sump Sensor(s). Model: ❑Fill Sump Saw*s). Model: <br /> ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: <br /> ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: <br /> ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: <br /> ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). <br /> Dispenser ID: Dispenser ID: <br /> ❑Dispenser Containment Scnsor(s). Model: ❑Dispenser Containment Scr sor(s). Model: <br /> ❑Shear Valve(s). ❑Shear Valve(s). <br /> ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑Dispenser Containment Sensor(s). Madel: ❑Dispenser Containment Sensot(s). Model: <br /> ❑Shear Valve(s). ❑Shear Valve(s). <br /> ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Cbam(s). <br /> Dispenser ID: Dispenser ID: <br /> ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: <br /> ❑Shear Valve(s). ❑Shear Valve(s). <br /> ❑Dispenser Containment Float(s)and Cham(s). ❑Dispenser Containment Float(s)and Chain(&). <br /> •If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification - I certify that the equipment identified in this document was Inspected/serviced in accordance with the <br /> manufacturers'guidelines. Attached to this Certification Is information(e.g.manufacturers'checklists)necessary to verify that this <br /> Information is correct and a Plot Plan showing the layout of monitoring equf ment. For any equipment capable of generating such <br /> reports,I have also attached a copy of the report;(check all that apply): il syste t-u Lj1arm history report <br /> Technician Name(print): Joe Barthodi Signature: 11Z t1-� <br /> Certification No.: B36852 License.No.: 0133 A-HAZ <br /> Testing Company Name: Elite IV Contractors Phone No.:(209) 461-6337 <br /> Testing Company Address: 2535 WIGWAM DR STOCKTON CA 95205 Date of Testing/Servicing: 10/20/2015 <br /> Page 1 of 3 <br /> Rev(2/08) <br />