COMPLIANCE INFO_2004-2009 - Laserfiche WebLink

Home Browse Search

E C E U AppendixVI JUL 1 4 2009 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available tNVIROWNIEN T HEALTH MONITORING SYSTEM CERTIFICATIOWRMIT/SpRVICES For Use By Aft 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 LIST systems within 30 days of test date. A. General Information Facility Name: Shell Bldg.No.: Site Address: 2494 Fremont St cit, Stockton zip: 95205 Facility Contact Person: Mike Contact Phone No.:(209 941-8743 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 1 7-9-09 B. Inventory of Equipment Tested/Certified -------Check the avoroDriate boxes to indicate s ific eauig)ment ins i ecte-diserviced: A� Tank k D: - - Tank ID- - - x In-Tank Gauging Probe. Model: x In-Tank Gauging Probe. Model:t 304 • Annular Space or Vault Sensor. Model: x Annular Space or Vault Sensor. Model: • Piping Sump/Trench Sensor(s). Model: ZVO x Piping Sump/Trench Sensor(s). Model: .x 1 _209- Fill Sump Sensor(s). Model: x Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model:-8482t- Mechanical Line Leak Detector. Model:_54U4 Electronic Line Leak Detector. Model: x Electronic Line Leak Detector. Model: Tank Overfill/High4-evel Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specifv a ui ment tvDe and model in Section E on Pens 2). Other(sDecifv egUiDment tvDe and model in Section E on Pane 2). Tank ID: Tank ID: 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 f High-Level Sensor. Model: Others Other(sDecdv eaulDment tvDe and model in Section E on Pane 2). Other(sDecifv equii)ment tvDe and model in Section E on Pane 2). he a Dispenser 10: 1/2 Dispe ser to:::: se r • Dispenser Containment Sensor(s). Model: :1Ud Dispenser Containment Sensor(s). Model: 208- • ShearValve(s). ShearValve(s). se on , Di Containment Float(s)and Chaln(s). DisDenser Containment Float(s)and Chaln(s). Dispenaler�ID: 010 Dispenser to: • Dispenser Containment Sensor(s). Model: 208 x Dispenser Containment Sensor(s). Model: 208 • ShearValve(s). K ShearValve(s). DisDenser Containment Float(s)and Chainw. Disnenser Containment Float(s)and Chain(s). Dispenser ID:7 I Disoenser to: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: W Shear Valve(s). Shear Valve(s) se,C.n D ria-Den ser Containment nment Float(s)and Chat in(s DimserCo�ainment Float(s)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 - I certify that the equipment Identified In this document was Inspectedisery Iced 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 Ala Istory rep qrt Signature: �4 Technician Name(print): Gavin WilliamsW 32 Certification No.: ICC# 8016288-UT License.No.: CSL B# 856711 Testing Company Name: Henderson Maintenance Company Phone No.:L209_j 467-7573 Testing Company Address:PO Box 31325 Stockton, CA 95213 Date of Testing/Servicing: 1 7-9-09 Monitoring System Certification Page I of 4 12/07 2/21/07