COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

MONITC*ING SYSTEM CERTIF ATION MAKE/ MODEL OF MONITORING SYSTEM: Incon TS -1000 CERTIFICATION / TEST DATE: October 30, 2012 A1. FACILITY Name Ramos Oil #4376 Address 10842 S. Harlan Road, French Camp, CA 95231 Phone # 800-477-7266 x 244 Contact Sam Delgado A2. OWNER Name Ramos Oil Address 1515 South River Road, West Sacramento, CA 95691 Phone # 916-371-2570 Contact Dave Nelson A3. C U P A Tank #2 (Product): ❑ A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health ❑ In -Tank Gauging Probe Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Dispenser # : 3-4s ■ Dispenser Containment Sensor(s) Model: Incon ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Address P.O. Box 1025, W. Sacramento, CA 95691 Notified October 16, 2012 Model: Incon Lic # 617238 A, B, Haz Inspector Thuy Tran Fill Sump Sensor(s) Mechanical Line Leak Detector Electronic Line Leak Detector Tank Overfill / High -Level Sensor Other (specify equipment in Section E) Contact Dulcinea Covan Phone # 209-468-8257 Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to indicate equipment inspected/serviced) Ri- TOAII[C Tank #1 (Product): Diesel Tank #2 (Product): ❑ In -Tank Gauging Probe Model: Dispenser ■ ■ ❑ ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: Incon Dispenser # : 3-4s ■ Dispenser Containment Sensor(s) Model: Incon ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: Incon ❑ Piping Sump / Trench Sensor(s) Model: ■ ■ ❑ ❑ ❑ Fill Sump Sensor(s) Mechanical Line Leak Detector Electronic Line Leak Detector Tank Overfill / High -Level Sensor Other (specify equipment in Section E) Model: Incon Model: VMI 99LD-2000 Model: Model: Model: _ ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment in Section E) Model: Model: Model: Model: Model: Tank #3 (Product): Tank #4 (Product): _ ❑ 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 in Section E) Model: ❑ Other (specify equipment in Section E) Model: 1=Yid fr I til umie 1.'1;]:t4-"1/1InI Wq 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): ■ System set-up ■ Alarm History Report WaX WALTON Signature: 01 ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: October 30, 2012 Dispenser # : 1-29 ■ Dispenser Containment Sensor(s) Model: Incon ■ Shear Valves ❑ Dispenser Containment Float(s) and Chains) Dispenser ■ ■ ❑ # : 2-38 Dispenser Containment Sensor(s) Model: Incon Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : 3-4s ■ Dispenser Containment Sensor(s) Model: Incon ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ■ ■ ❑ # : 4-5s Dispenser Containment Sensor(s) Model: Incon Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser ■ ■ ❑ # : 5 Dispenser Containment Sensor(s) Model: Incon Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) 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): ■ System set-up ■ Alarm History Report WaX WALTON Signature: 01 ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: October 30, 2012