COMPLIANCE INFO_2009-2018 - Laserfiche WebLink

Home Browse Search

t Appendix VIS °' � 1 Rti, u. .. MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California l 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 pre f a # each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the TH tank ss e 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 ` rR a 1 A. General Information Facility SJC SHERIFFS OP Bldg.No.: N.. 9. Site Address- 7000 N MICHAEL CANLIS City: FRENCH CAMP CA Zip: Facility Contact Person' Contact Phone No.: ( ) Make/Model of Monitoring System: VEEDER ROOT TLS 350 Date of Testing/Servicing: 1-26-18 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific a ui ment ins ected/serviced: Tank ID: 87 OCT TanklD: DSL ® In-Tank Gauging Probe. Model: MAG 1 ® In-Tank Gauging Probe. Model: MAG 1 ® Annular Space or Vault Sensor. Model: 409 ® Annular Space or Vault Sensor. Model: 409 ® Piping Sump/Trench Sensor(s). Model: 208 ® Piping Sump I Trench Sensor(s). Model: 208 ❑ 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(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID: 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: ❑ 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(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: DSL Dispenser ID: ® Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® ShearValve(s). ❑ ShearValve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: GAS Dispenser ID: ® Dispenser Containment Sensor(s), Model: 208 ❑ Dispenser Containment Sensor(s). Model: ® ShearValve(s). ❑ ShearValve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ ShearValve(s). ❑Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(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.Certification-1 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 all that apply): ❑System set-up ❑Alarm history report Technician Name(print): DAVE WINKLER Signature: Certification No.: 5263373-UT License No: 08-1739 Testing Company Name: AFFORDA-TEST Phone No. (209)744-0113 Testing Company Address: 416 2nd STREET GALT,CA 95632 Date of Testing/Servicing: 1-26-18 Monitoring System Certification Page 1 of 4 2/21/07