COMPLIANCE INFO_2015-2016 - Laserfiche WebLink

Home Browse Search

RECEIVED Monitoring System Equipment Certification FEB 2 2 2016 For Use By All Jurisdictions Within The State of California Authority Cited:Chapter 67,Health and Safety Code;Chapter 16,Division 3, Title 23, California Code o NMENTAL . A1TH rWPAPTMFNT 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 system within 30 days of test date. A. General information Facility Name:Chevron Bldg.No.: Site Address: 1960 W.11th St City: Tracy,CA Zip: 95376-3738 Facility Contact Person: Helen Contact Phone No.: (209)836-3181 Make/Model of Monitoring System: VR TLS-350 Date of Testing/Servicing: 1125116 B. Inventory of Equipment Tasted/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced- Tank IDL0I-Prem Tank ID: 02-Requ In-Tank Gauging Probe. Model: VR 847390.108 to In-Tank Gauging Probe. Model: VR 847390-10e Annular Space or Vault Sensor. Model: VR 794390408 Annular Space or Vault Sensor. Model: VR 794390469 Piping Sump\Trench Sensor(s). Model: VR 794380.209 ® Piping Sump\Trench Sensor(s). Model: VR 794380-209 Fill Sump Sensor(s). Model VR 794380-209 Fill Sump Sensor(s). Model: VR 794380-209 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model; Electronic Line Leak Detector. Model: VR series 8484 Electronic Line Leak Detector. Model VR series 8484 ® Tank Overfill\High-Level Sensor. Model: tgts_G=_ ® Tank Overfill\High-Level Sensor. Model cx- ❑ Other(specify equipment type and model in Section E oR Page 2). ❑ Other(specify equipment type and model in Section E 4tfPage 2). Tank ID:03-Diesel Tank IIS; tj In-Tank Gauging Probe. Model: VR 848390-109 ❑ in-Tank Gauging Probe. Model: I& Annular Space or Vault Sensor. Model: VR 794390.409 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: VR 794380-209 ❑ Piping Sump\Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: VR 794380.209 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector. Model: VR series 8494 ❑ Electronic Line Leak Detector. Model: Tank Overfill\High-Level Sensor. Model:C ❑ Tank Overfill\High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E Dn Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser IQ* 01.02 Dispenser ID• 03-04 ® Dispenser Containment Sensor(s). Model: VR 794380-208 Dispenser Containment Sensor(s). Model: VR794380-208 ® Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser lD• 05-06 Dispenser ID: 07-08 ® Dispenser Containment Sensor(s). Model: VR 794380-208` Up Dispenser Containment Sensor(s). Model: vR 794380-20-8 Shear Valve(s). ® Shear Valve(s). p Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 09-10 Dispenser ID: 11-12 1111 Dispenser Containment Sensor(s). Model: Vit 794380.208 11 Dispenser Containment Sensor(s). Model: Vit 794380.208 11 Shear Valve(s). 1$ 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- I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'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,l have also attached a copy of the; (check all that apply): 19 System set-up 11 Alarm history report Technician Name(print):Marcos Mercado Signature: �J r t ise&, Mfg.Cert.#.: 836955 ICC# 8049069-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 96112 Date of Testing/Servicing: 1/25116