COMPLIANCE INFO_2017-2018 - Laserfiche WebLink

Home Browse Search

RECEIVED Appendix VI JUL 17 2018 (Copies of Monitoring System Certification form and UST Monitoring Plot Pian available at http://www.waterboards.ca,gov.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions Within the State of California HEALTH DEPARTMENT 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 ownerloperator 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: Kaiser Manteca Bldg.No.: Site Address: 1777 W.Yosemite Avenue City:Manteca Zip: 96337 Facility Contact Person: Contact Phone No.:( ) MakelModel of Monitoring System: Veeder-Root TLS-350 Date of Testing/Servicing: 6127/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicatespecific equipment Ins acted/serviced: Tank ID: T1 Diesel Tank AST Tank ID: T2 UST Diesel V In-Tank Gauging Probe. Model: us V In-Tank Gauging Probe. Model: 8 Annular Space or Vault Sensor. Model:794390-420 Annular Space or Vault Sensor. Model: d Piping Sump/Trench Sensor(s). Model:794380-208 Piping Sump/Trench Sensor(s). Model:7940-208-- J Fill Sump Sensor(s)_ Model:794380-208 Flll Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector_ Model: V Tank Overfill/High-Level Sensor. Model:Annunciator Tank Overfill/High-Level Sensor. Model:Annunciator Other(s22cify equipment t and model in Section E on Page 2)_ Others ecify a ul ent a and model in Section E on Pae 2). TankiD: TanklD: 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: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(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 Ls2ecify a ui ment tyE and model in Section E on Pape 2). Other(specify a u mart t =d model in Section E on Pa e 2. DispenserlD: penserlD: Dispenser Containment Sensor(s). Model: _ Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains. IlDisEenser Containment Floats and Chains. Dispenser lD: Dispenser ID: Dispenser Containment Sensor(s). Model Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dis enser Containment Float(s)and Chain(s). H Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensogs). Model II Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains Dis enser Containment Float(s)and Chains. 'If the facility contains more tanks or dispensers,copy this for;;. 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 Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report;(checkoff that apply): k System set-up WAlarm history report Technician Name(print): David Walker Signature: \,A Jk, Certification No.: A32030 License.No.: 808313 Testing Company Name: Belshire Environmental Services, Inc. Phone No.:( 949 )460-5200 Testing Company Address: 25971 Towne Centre Dr.,Foothill Ranch,CA 92610 Date of Testing/Servicing: 6/2712018 Monitoring System Certification Page 1 of 4 12/07