COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

RECEIVED 2014 Appendix VI rN 110N (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http_11 11 I MERVICES 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: _Ramos Oil Company Bldg.No.: Site Address:_10842 S. Harlan Road city:_French Camp zip: Facility contact Person:,Steve Richardson Contact Phone No.:916-371-2570 Make/Model of Monitoring System:_TLS-350 Date of Testing/Servicing:_10/30/14 B. Inventory of Equipment Tested/Certified Check the aegropriate boxes to indicates cific a ui ment insll ectediserviced: Tank ID:_1 Diesel Tank 10: ❑ In-Tank Gauging Probe. Model: x In-Tank Gauging Probe. Model:_Mag 1 Annular Space or VauR Sensor. Model: x Annular Space or Vault Sensor. Model: VR 303 ❑ Piping Sump/Trench Sensor(s). Model: x Piping Sump I Trench Sensor(s). Model: VR 208 ❑ Fill Sump Sensor(s). Model: x Fill Sump Sensor(s). Model: VR 208 - Mechanical Line Leak Detector. Model: x Mechanical Line Leak Detector. Model: VMI LD 2000 ❑ 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). i Other(s22n equieMent and model in Section E on Page 2). Tank ID: Tank 10: ❑ 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: n 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(spectl a ut mentUP2 and model in Section E on Pa e 2). ❑ Other(sg2n e ui ment a and model in Section E on Pae 2L Dispenser 10:_122 Dispenser ID:_3-4 x Dispenser Containment Sensor(s). Model: VR 208 x Dispenser Containment Sensor(s). Model:_VR 208 ❑ Shear Valve(s). Shear Valve(s). ❑ Disp2nser Containment Float(sj and Chain(s). _; Dispenser Containment Floats and Chain(s). Dispenser 10:_Satellite 1 Dispenser ID:_Satellite 4-5 x Dispenser Containment Sensor(s). Model: VR 208 x Dispenser Containment Sensor(s). Model: VR 208 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chains. Dispenser 10:_Satellite 2-3 Dispenser ID:—5 x Dispenser Containment Sensor(s). Model:_VR 208 x Dispenser Containment Sensor(s). Model: VR 208 ❑ Shear Valve(s). ❑ Shear Valve(s). n Dispenser Containment Floats and Chains _ Dispenser Containment Floats and Chains. *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 are 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,1 have also attached a copy of the report;(check all that apply): System set-up n Alarm histo ownt c �/ Technician Name(print):Gabe Garcia Signature: Certification No.: B42919 License.No.: 811471 Testing Company Name:`JP Petroleum Service Phone No.:(_916__)_372-5693 Testing Company Address:3065 Asante Lane, W. Sacto Ca 95691_, Date of Testing/Servicing:_10-30/14 Monitoring System Certification Page 1 of 4 12107 1 2/21/07