COMPLIANCE INFO_2007-2015 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION For Use By All 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: California Stop Bldg.No. — Site Address: 2224 Manthey Road City: Stockton, CA Zip: 95206 Facility Contact Person: Timmy Le Contact Phone No: 209-406-1484 Make/Model of Monitoring System: V/R TLS 350 Date of Testing/Servicing: 3/11/2014 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: 1 - 87 Tank ID: 3 - Diesel 0 In-Tank Gauging Probe. Model: MAG-1 0 In-Tank Gauging Probe. Model: MAG-1 0 Annular Space or Vault Sensor. Model: 407 0 Annular Space or Vault Sensor. Model: 407 0 Piping Sump/Trench Sensor(s). Model: 208 0 Piping Sump/Trench Sensor(s). Model: 208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 99LD2000 0 Mechanical Line Leak Detector. Model: 99LD2000 ❑ 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 a and model in Section E on Page 2). ❑ Other(specify equipment and model in Section E on Pa e 2). Tank ID: 2 - 91 Tank ID: 0 In-Tank Gauging Probe. Model: MAG-1 ❑ In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 407 ❑ Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: 208 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 99LD2000 ❑ 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 t and model in Section E on Pa e 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1 / 2 Dispenser ID: 7/ 8 0 Dispenser Containment Sensor(s). Model: 208 0 Dispenser Containment Sensor(s). Model: 208 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dis nser Containment Floats and Chain(s). I ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3 / 4 FUDispenser nser ID: 0 Dispenser Containment Sensor(s). Model: 208 Containment Sensor(s). Model: 0 Shear Valve(s). ear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). spenser Containment Float(s)and Chain(s). Dispenser ID: 5/ 6 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 208 ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ Shear Valve(s). ❑ Dis nser 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 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): O System set-up O Alarm history report Technician Name(print): Al Milburn Signature: Lz_ Certification No: A27843 License No. 956593 Testing Company Name: EPIC Environmental Compliance Systems Inc. Phone No. 888-700-EPIC Testing Company Address: 1435 Huntington Ave, Suite 230 South San Francisco, CA 94080 Date of Testing/Servicing: 3/11/2014 UN-036-1/4 Page 1 of 4 Rev.06/04/01 www.unidocs.org