COMPLIANCE INFO_2014-2018 - Laserfiche WebLink

Home Browse Search

0 RECEIVED ' Appendix VI (Copies of Monitoring System Certification form and UST'MonkoringPlot Plan available athttp:G%www.waterboar s.2o1J ca gov .) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions W'ith�r the State of California WI:Al T1 -t ncmAQTARr-klT Authority Cited: Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code ofRegulations 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 perforans the work. A copy of this form must be provided to the tank system owner/operator owner/operator must submit a copy ofthis form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Unified Grocers, Inc Facility ID: 01 Site Address: 1990 Piccoli Rd. Facility Contact Person: Mike Young Make/Model of Monitoring System: Veeder Root TLS -350 City: Stockton Zip: 95215 Contact Phone No.: 209-931-7416 Date of Testing/Servicing: 2015-11-23 The B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: -Tank 1. Die. �_.847390 109 Tank Tank ID: _ ginglPro..... _....e.. ....._� _,® I Tank ID X Gauging be. Model: 1JankGauging Probe. Model i EFX� Annular Space or Vault Sensor. Model: 794390-420 ❑ Annular Space or Vault Sensor. Model: 2 e1iO Piping Sump / Trench Sensor(s). Model: 794380-205 ❑ Piping Sump/ Trench Sensor(s). Model: i( 4 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: STP-MLLD-D ❑ Mechanical Line Leak Detector. Model: TElectronic Line Leak Detector. Model: J❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High-l..evel Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ijM Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). 11 Tank ID: Tank ID: [i €❑ In -Tank Gauging Probe. Model: �❑ In=I'ankGauging 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(,). Model: ❑Fill Sump Sensor(,). Model: II ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: [I Electronic Line Leak Detector. Model: E IQTank Overfill/ High -Level Sensor. Model: ; ❑ Tank Overfill / High -Level Sensor. Model: �'❑ Other (specify equipment type and model in Section E on Page 2) ❑ Other (spent} equipment type and model m Section E on Page 2) _,.. _ i�F7 Dispenser Containment Dispenser ID: Sensor(s). Dis Dispenser ID: Sensor(s). Model: 1❑ Dispenser Containment Senso s . Model: �❑ Shear Valve(,). 1❑ Shear Valve(,). ❑ Dispenser Containment Float(s) and C'hain(s).❑ Dispenser Containment Float(s) and Chain(s). 9i P (s) i 11Dispenser ID: (iDispenser ID: 0 Dispenser Containment Sensor(s). Model: li❑ Dispenser Containment Sensor(s). Model: I_❑ Shear Valve(s). [i❑ Shear Valve(s). i❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s),I *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 manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify, that this information is correctand 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 Q Alarm history report Technician Name (print): Victor Guerrero 1�a Signature: Certification No.: 836532 License. No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SERVICES Phone No.: 714560-8222 Testing Company Address: 2131 soUTirDUPONT DRIVE, ANAHEMI CA 92S06 Date of Testing/Servicing: 2015-11-23