COMPLIANCE INFO_2014-2017 - Laserfiche WebLink

Home Browse Search

a 10 6f1TlE8-RrANlac. 01 GR Job# 20-641624 Appendix VI rRECHWED MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia ENVIRONMENTAL HEALTH Authority Cited.Chapter 6.7, Health and Safety Code;Chapter 96,Division 3, Title 23, CWftn9&AW9 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 UST systems within 30 days of test date. A. General Information Facility Name: Arco SS 5450 Bldg.No.: Site Address: 1617 W.Fremont City: Stockton,CA Zip: Facility Contact Person: Sarah Samuels Contact Phone No.: 360-526-3917 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 7/2 612 01 6 B. Inventory of Equipment Tested/Certified Check the approeriste boxes to Indicates cific a ul merit inspects,dtserviced: Tank ID: 87-1 Tank ID: 87-2 ® In-Tank Gauging Probe. Model: 847390-107 13 In-Tank Gauging Probe. Model: 847390-107 13 Annular Space or Vault Sensor. Model: 794390 10 Annular Space or Vault Sensor. Model: 794390409 ® Piping Sump/Trench Sensor(s). Motel: 794380-208 13 Piping Sump/Trend Sensor(s). Model: 794380-208 ® Fill Sump Sensor(s). Model: 794380-344 13 Fill Sump Sensor(s). Model: 79 -344 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ® Electronic Line Leak Detector Model: 848480 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other LSUAX 2quipment IMe and model in Section E on P e 2). ❑ Other(specifyMuigment type and model in Section E on Pae 2). Tank ID: 91 Tank ID: 13 In-Tank Gauging Probe. Model: 847390.107 ❑ In-Tank Gauging Probe. Model: 13 Annular Space or Vault Sensor. Model: 794390-409 ❑ Annular Space or Vault Sensor. Model: ED Piping Sump/Trench Sensor(s). Model: 0.20 ❑ Piping Sump/Trench Sensor(s). Model: IM Fill Sump Sensor(s). Model: 79438041144 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. el: 13 Mechanical Line Leak Detector. Model: 13 Electronic Line Leak Detector Model: 848 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other isoeciU gquipment type and model in Section E on Page 2). 1 ❑ OtherjjR2c&Mui2ment b2e and model in Section E on Pae 2. Dispenser ID: 1/2 Dispenser ID: 314 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Diseinser Containment Floats and Chain(s). ❑ Dis nser Containment Floats and Chain(s). Dispenser ID: 516 Dispenser ID: 718 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Dispenser Containment Sensor(s). Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). 113 Dispenser Containment Floats 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 Floats and Chain(s). ❑ Disp2nser Containment Floa 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 Inspectediserviced 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 ® Alarm history report Technician Name(print): Elodio Sanchez Signature: Certification No.: 841204 License.No.: 220793 Testing Company Name: Getder-Ryan Inc. Phone No.: 925-551-7555 Testing Company Address: 6805 Sierra Court#G, Dublin,CA 94568 Date of Testing/Servicing: 7/26/2016 Monitoring System Certification Page 1 of 4 12/07 1