COMPLIANCE INFO_2013-2017 - Laserfiche WebLink

Home Browse Search

WO -8286 MONITORING SYSTEM CERTIFICATION For Use B�yAll Jurisdictions Within the State of California Authority Cited: Chapter 6.7. Health and Safety Code; Chapter IS, Division j, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or r92QL1 Mg§t e prepared for each £nonitorine system conteol 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. =N001 717M M11 Facility Name: United Pacific 5447 Site Address: 1469 E. Hammer Ln. Facility Contact Person: Make/Model of Monitoring System: Veeder-Root TLS -350 B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate enarifir ons.1nmant inen—t,olle-4-1- City: Stockton Contact Phone No.: Bldg. No.:_ Zip: 95210 Date of Testing/Servicing: 9/6/2017 ....... ... Tank ID: Diesel Tank ID: F-1 In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: 794390-409 0 Annular Space or Vault Sensor. Model; 0 Piping Sump! Trench Sensor(s). Model: Piping Sump i Trench Sensor(s). Model; C] Fill Sump Sensor(s). Model: Fill Sump Sensor(s), Model: C] Mechanical Line Leak Detector. Model: C] Mechanical Line Leak Detector. Model: C] Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: Tank Overfill i'High-Level Sensor. Model: 0 Tank Overfill / High -Level Sensor, Model: Other (specify equipment type and model in Section E on Page 2). [3 Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: El In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: [:] Annular Space or Vault Sensor. Mode): 0 Annular Space or Vault Sensor. Model: E] Piping Sump / Trench Sensor(s). Model: [] Piping Sump) Trench Sensor(), Model: E] Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: [:] Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: E] Electronic Line Leak Detector. Model: [] Electronic Line Leak Detector, Model: Tank Overfill 1high-Level Sensor.. Model: 0 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: Dispenser ID: ODispenser Containment Sciiior(s). Model: []DisptvserContainment Sciisorts). Model: ❑Shear Valve(s). 0 Shear Valve(s). ❑ Dispenser Containment Floats) and Chain(s). [71 Dispenser Containment Floats) and Chain(s), MEE= Dispenser ID: Dispenser ID: 0 Dispenser Containment Scosot(s). Model: []DispetiserCoittaitimentSensor(s). Model; 0 Shear valve(s). [] Shear Valve(s). Dispenser Containment Floats) and Chants). [3 Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containincut Sensoqs). Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve($). ❑ Shear Valve(s). Dispenser Contac nnicut Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s), *If tile facility contains more tanks or dispensers. coriv 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 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): [D System set-up ®Alarm history report Technician Name (print): Pat Armour Certification No.: A20284,8141940 -UT Signature: License. No.: 499721 Testing Company Name: Armour Petroleum Servicc,& Egaipment Corporation Phone No.: (707) 437-6668 Testing CompanyAddress: 2400 Cement Hill Rd., B3, Fairfield, CA 94533 — Date of Testing/Servicing: 9/6/2017 Page I of 3 Rev (2/08)