COMPLIANCE INFO_2018 - Laserfiche WebLink

Home Browse Search

0 0 GITTUR-RYAN kC. GR Job# Appendix V1 SWRCB,January 2006 MONITORING SYSTEM CERTIFICATION AUG 10" 2018 For Use By All Jurisdictions Within the State of California Authority Cited.,Chapter&7,Health and Safety Code;Chapter 16,Division 3, Tide 23, Cal'ARNW094WNTAL Regulations HEALTH DEPARTMENT 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 LIST systems within 30 days of test date. A. General Information Facility Name: Arco 5450 Bldg.No.: Site Address: 1617 W. Fremont city: Stockton Zip: 95203 Facility Contact Person: Daryl Lee Contact Phone No.: 415-902-5089 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 7/19/2018 B. Inventory of Equipment Tested/Certified Check the rlate boxes to Indicate seMlfic!9g2=nt ins - Tank ID: 87-M Tank ID: 87-S In-Tank Gauging Probe. Model: Q!17320-1 07 0 In-Tank Gauging Probe. Model: $47390-107 Annular Space or Vault Sensor. Model: 221390-409— 0 Annular Space or Vault Sensor. model: 794390-409 Piping Sump/Trench Sensor(s). Model:�94 3 8�- 0 Piping Sump/Trench Sensor(s). Modd: 72!1380-208 Fill Sump Sensor(s). Model: 721380-31:1 0 Fill Sump Sensor(s). Model: 794380-344 Mechanical Line Leak Detector. Model: 13 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector Model: 848480 E3 Electronic Line Leak Detector Model: Tank Overfill/High-Level Sensor. Model- 3M 7- 0 Tank Overfill/High-Level Sensor. Model: Vg Other(specify equipment type and model in Section E on Page 2). C3 Other Lsj22EUequjement and model in Section E on EW 2). Tankil). 93 TankID: In-Tank Gauging Probe. Model: 847390-107 E3 In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 79439(3-409'- E3 Annular Space or Vault Sensor. Model: Piping Sump I Trench Sensor(s). Model: 794380-208 E3 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 724300-344 E3 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Li mechanical Line Leak Detector Model: Electronic Line Leak Detector Model: 8 8 4 8 0 13 Electronic Line Leak Detector Model: Tank Overfill/High-Level Sensor. Model: VR E3 Tank Overfill/High-Level Sensor. Model: Other J!22M equipment type and model in Section E on P 2). E3 Other&22&equipment bo and model in Section E on P 2). Dispenser ID: 1-2 Dispenser ID: 3-4 Dispenser Containment Sensor(s). Model: _294380-2as 0 Dispenser Containment Sensor(s). Model: 79438Q-2Q§ ShearValve(s). 0 ShearValve(s). DIsF=ser Containment Float(sj and Chai!A!�. 113 Dispenser Containment Fl2aLs)and Chain(s). Dispenser ID: 5-6 11 Dispenser ID: 7- Dispenser Containment Sensor(s). Model: 724380-208 0 Dispenser Containment Sensor(s). model: 791380-UO ShesrValve(s). 0 ShearVaivs(s). DjNnLmw Containment Float(s)and Chains. . 11 0 Dispenser Containment Float(s)and Chain(s). Dispenser 10: -1[-01spenser ID. Dispenser Containment Sensor(s). Model: Q Dispenser Containment Sensor(s). Model: ShearValve(s). 13 ShearValve(s). Dispenser Containment Float(s)and ChalnUa. 13 DIsp!nser Containment Float(sj anELChai 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 Inepectediserviced In accordance with the manufacturers' guidelines. Attached to this Certification Is Information (eg. manufacturers' checklists) necessary to cos at this Information Is correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable.of gen ng attached a copy of the report;(check all that apply): System set-up El Alarm h report Technician Name(print): David Rouse Signature: Certification No.: VR#B44848-ICC 8292530 License.No.: 220793 Testing Company Name: GeNer-Ryan Inc. Phone No.: 925-661-7556 Testing Company Address: 6806 Sierra Court Suite G.,Dublin CA 94668 Date of Testing/Servicing: 7/19/2018 Monitoring System Certification Page I of 4 12/07 1