COMPLIANCE INFO_2013-2018 - Laserfiche WebLink

Home Browse Search

Mar.21, 2016 9:34AM # No -2450 P, 5 14 MONII RING SYSTEM CERTIFIC ION F crq * ions Within the State of Cali "nia or 3 'Ift J�Js do HealthSafety ode;' Authority Cited: Chapter 6.7, H Ith aChapter 16, Division 3, Tit a 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate Monitoring system control panel by the technician who performs the work, A copy of this form must be pro or. The owncr/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information MAR 2 12016 Facility Name: H&M KWIK SERVE W"MENTAL Site Address- 2601 E. JACKSON -rg,- City: ESCALON, CA 1� °463207%rr Facility Contact HASSAN Contact Phone No.; (209) 838-3971 Make/Model of Monitoring VEEDER ROOT TLS -360 Date of Testing/Servicing: 3117/2016 1B. Inventory of Equipment TestedlCertified Check appropriate boxes to indicate specific NUIPMent inspeckd/gerviced; Tank ID: 87 Tank](D. 91 23 In -Tank Gauging Probe. Model: veeder root W In -Tank Gauging Probe. Model: veeder root 121 Annular Space or Vault Sensor. Model; 420 0 Annular Space or Vault Sensor. Model: 420 0 Piping Sump / Trench Sensor(s). Model; 208 N Piping Sump / Trench Sensor(s). Model: 208 [I Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: M Mechanical Line Leek Dot wor. Model: RED JACKET 0 Mechanical Line Leak Detector. Model: RED JACKET 0 Electronic Line Leak Detector. Model- El Electronic Line Leek Detector. Model: 0 Tank Overfill / Ifigh-Level Sensor, Model: FLAPPER 0 Tank Overfill I High -Level Sensor. Model; FLAPPER El Other (specify equipment type and model in Section E on Page 2). n Other (specify equipment type and model in Section F on Page 2). Tank ID: DSL Tank ID: 0 in -Tank Gauging Pfobc. Model: veeder root El In -Tank Gauging Probe. Model: [9 Annular Space or Vault Sensor. Model: 420 [] Annular Space or Vault Sensor. Model: 0 Piping Sump /Trench Semor(s). Model. 208 C3 Piping Sump I Trench Sensor(s). Model; D Fill Sump Scrisor(s). Model: [I Fill Sump Sensor(s). Model: [0 Mechanical Line Leak Detector. Model: RED JACKET D Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill I High -Leve) Sensor. Model: FLAPPER Tank Overfill 114igh-Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). F-1 Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 112 Dispenser ID! [I Dispenser Containment Sensot(s). Model: ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). Shear Valve(s). Dispenser Containment Floats) and Chain(s). ..". . . . ....... . .............. Dispenser Containment Float(s) and Chain(s). Dispenser ID: 314 Dispenser ID; 0 Dispenser Containment Semor(s), Model: El Dispenser Containment Sen"s), Model:_ 0 Shear Valve(s). D Shear Valve(s). [4 Dispenser Containment Float(s) and Chain(s). t] Dispenser Containment Flost(s) and Chain(s). Dispenser ID; Dispenser ID; M Dispenser Containment Sensor(s). Model: El Dispenser Containment SensoT(s). Model: 0 Shear Valve(s). [I Shear Valve(s). 9 Dispenser Containment Floats) and Chain(s), 0 Dispenser Containment Float(s) and Chain(s). ,41- the facility contains more tanks or dispensers, copy this form. include information for every tank and dispenser at the facility Certifleation -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 euipment For any equipment capable of generating such reports, I have also attached a copy of the report; (check ft/1 that apply): $ystem. set-up E] Alarm history report Technician Name GABRIEL VENEGAS Signature: Certification No.: 840893 License. No,: Testing Company Testing Company LSC SERVICES Phone No.; (559) 444-1730 3887 N VALENTINE FRESNO CA 93722 Date of Te-sting/Servicing: 311712016 Page I of 3 Rey (2/08)