COMPLIANCE INFO_2001-2007 - Laserfiche WebLink

Home Browse Search

i MONIT !�G SYSTEM CETIFI*CJi ION F All Jurisdictions Within the State of Californ Authority Cited.Chapter 6.7,Hea and Safety Code,Chapter 16,Division 3 Title 23ia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,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: CHEVRON 201761 City: MANTECA CA Zip:95337 Site Address: 1103 S.MAIN ST. Contact Phone No: 825-0174 Date of Testing/Service: 04/04/2006 Facility Contact Person: MGR-MARIE Make/Model of Monitoring System:VRTLS350 Work Order Number. 2241954 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: 1 TankiD: 2 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 407 21 Annular Space or Vault Sensor. Model: 407 X Piping Sumplrrench Sensor(s). Model: 208 Piping Sump/Trench Sensor(sk Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: 71 Electronic Line Leak Detector. Model: PLLD X Electronic Line Leak Detector. Model: PLLD Tank Overfill/High-Level Sensor. Model: MECHANICAL X Tank Overfill/High-Level Sensor. Model: MECHANICAL Other(specify equipment type and model in Section E on page 2). Otherequipment(specify eq p type and model in Section E on page 2). TanklD: J TanklD: X in Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 407 Annular Space or Vault Sensor. Model: X Piping Sumpfrrench Sensor(s). Model: 20$ 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: X Electronic Line Leak Detector. Model: PLLD Electronic Line Leak Detector. Model: X Tank Overfilill-ligh-Level Sensor. Model: MECHANICAL 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 : 1/2 Dispenser ID: 3/4 X Dispenser Containment Sensor(s) Model:208 X Dispenser Containment Sensor(s) Model:208 X Shear Valve(s). X Shear Valve(s) Dispenser Containment Float(s)and Chain(s). 7 Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 ® Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s). Model:208 ® Shear Valve(s). 71 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 ® Dispenser Containment Sensor(s) Model:208 X Dispenser Containment Sensor(s). Model:208 Shear Valve(s). X Shear Valve(s). ElDispenser 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 Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): ®System set-up Alarm history report Technician Name(print): RAYMOND SIMMS Signature: Certification No.: 006-05-0282 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 04/04/2006 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01