COMPLIANCE INFO_2011-2013 - Laserfiche WebLink

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K. i t' riHca 'on y 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 eat '9 t -, r prepared for each monitoring system control panel by the technician who performs the work. A o � i °M{ t '6V o ed to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. 0 C 1 2 J 2013 A. General Information EN I Facility Name:Valero 3641 H � a �� - Site Address: 1210E Hammer Ln City: Stockton,CA Zip: 95210- Facility Contact Person: Manager Contact Phone No.:_(209)477-3111 Make/Model of Monitoring System: Gil EMC Date of Testing/Servicing: 9124/13 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank W:01-Regu Tank M: 02-Plus ® In-Tank Gauging Probe. Model: GBco PA02820960100 ® In-Tank Gauging Probe. Model: GBco PA02651320100 I& Annular Space or Vault Sensor. Model: VR 794390.40 ® Annular Space or Vault Sensor. Model: VR 794390-460 to Piping Sump\Trench Sensor(s). Model:--YR 784360-208 11 Piping Sump\Trench Sensor(s). Model: VR 794380.208 IN Fill Sump Sensor(s). Model: VR 794360-208 11 Fill Sump Sensor(s). Model: VR 794380-298 ❑ Mechanical Line Leak Detector. Model RJ 119.056.9 ❑ Mechanical Line Leak Detector. Model: RJ 118-066-8 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill\High-Level Sensor. Model: VR790091-001 ❑ Tank Overfill\High-Level Sensor. Model: VR79009i-001 ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank TD: 03-Prem Tank ID: IN In-Tank Gauging Probe. Model: GBco PA02651320100 ❑ In-Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: VR 794390.420 ❑ Annular Space or Vault Sensor. Model: ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 ❑ Piping Sump\Trench Sensor(s). Model: ® Fill Sump Sensor(s). Model: VR 793380-208 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: RJ 11 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill\High-Level Sensor. Model: VR 790091.001 ❑ 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 ID• 01-02 Dispenser ID- 03-04 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: IN Shear Valve(s). 11 Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser D- 05-06 Dispenser ID• 07-08 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). Shear Valve(s). ® Dispenser Containment Float(s)and Chain(s). ® Dispenser Containment Float(s)and Chain(s). Dispenser ID• Dispenser ID• ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser 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 manufacturer's guidelines. Attached to this Certification h information(e.g.manufactures'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; (cheek all thatapply): ® System set-up ® Alarm history report Technician Name(print): Kris Bell Signature: Mfg.Cert.#.: B33709 ICC# 5297793-UT License.No.: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave.,San Jose,CA 96112 Date of Testing/Servicing: 9124113