COMPLIANCE INFO_1990-2003 - Laserfiche WebLink

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am State and local laws regulations require that equipment which monitors tanks and/or piping systems containing hazardous materials be tested/serviced annually or on a schedule specified by the manufacturer, whichever is more frequent. This form, or a service report with equivalent information, must be used to document testing and servicing of monitoring equipment. If more than one monitoring system (e.g. Veeder-Root TLS -350, Ronan X76S, etc.) is installed at the facility, a separate certification or report must be prepared for each monitoring system by the technician who performs the work. Date of Testing/Servicing: Site Address: 2375 Grantline Rd. Facility Contact Person: Bonnie 3-23-00 Facility Name: Shell City: Tracy Zip: 95376 Contact Phone No.: (209) 836-8908 Make/Model of Monitoring System: Veeder Root/Simplicity Location of Control Panel: Back Room Make/Model of Line Leak Detector (LLD): Complete the following checklist: Veeder Root/PLLD LLD Leak Threshold: 3.0 g.p.h. X Yes Tank ID No.: Premium No* Monitoring system isoperable per manufacturer'sspecifications? X Yes X Annular Space Sensor No* Audible alarm iso erational? X Yes Piping Sump Sensor No* Visual alarm isoperational? X Yes X No* Monitoring system is secured from unauthorized tam erin ? X Yes Dispenser Containment Sensor(s) No* For pressurized piping systems, do the turbines automatically shut down if the monitoring system detects a leak, fails Dispenser Containment Sensor(s) Dispenser Containment SensOr(S) Mechanical Line Leak Detector to operate, or is electrically disconnected? If yes, which monitoring devices initiate positive shut down? Mechanical Line Leak Detector Mechanical Line Leak Detector N/A Electronic Line Leak Detector X Electronic Line Leak Detector Electronic Line Leak Detector X PLLD/WPLLD and Turbine Sensors X Yes Fill Sump Sensor No* For monitoring systems which serve as tank overfill warning devices, does the overfill warning function operate Fill Sump Sensor TLM Sump Sensor TLM Sump Sensor properly? If so, at what percent of tank capacity does the alarm trigger? 90% TLM Sump Sensor N/A *In the comments section below, describe how and when these deficiencies will be corrected. Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID No.: Regular Tank ID No.: Plus Tank ID No.: Premium Tank ID No.: Diesel Annular Space Sensor X1 Annular Space Sensor X Annular Space Sensor X Annular Space Sensor Piping Sump Sensor X Piping Sump Sensor x Piping Sump Sensor X Piping Sump Sensor In -Tank Gauging Probe X In -Tank Gauging Probe X In -Tank Gauging Probe X In -Tank Gauging Probe Dispenser Containment Sensor(s) Dispenser Containment Sensor(s) Dispenser Containment Sensor(s) Dispenser Containment SensOr(S) Mechanical Line Leak Detector Mechanical Line Leak Detector Mechanical Line Leak Detector Mechanical Line Leak Detector Electronic Line Leak Detector X Electronic Line Leak Detector Electronic Line Leak Detector X Electronic Line Leak Detector Fill Sump Sensor Fill Sump Sensor Fill Sump Sensor Fill Sump Sensor TLM Sump Sensor TLM Sump Sensor TLM Sump Sensor TLM Sump Sensor 11 Are impact valves operational per manufacturer's specifications? I X I YES I I NO Comments: I certify that the equipment identified above was inspected/serviced in accordance with manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturer's checklist, etc.) necessary to verify that the above information is correct and to describe any repairs, replacement, or recalibration of equipment. Name of Qualified Technician (print): John Talbott Signature: Signature on file at SSS. Testing Company Name: Service Station Systems, Inc. Phone No.: (408) 971-2445