COMPLIANCE INFO_2008-2011 - Laserfiche WebLink

Home Browse Search

JUL-04-2011 09:52 Service Station Systems 408 938 8888 P.07 Monitoring ste Equipment is i Flo,Use By All Jurissdictiomv Within The State of California Authority Cited., Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 2.3, California Code of'Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or rM2gXLtrt}�5t be F1rSpiir=d for emch monitoring sv,.stam ggjijEQI panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. 'rhe owner/operator must submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General information Facility Name:Shell 136187 Bldg.No.: Site Address: 2375 W. Grant Line City: Trap CA Zip: 95376 Facility Contact Person: Manager Contact Phone No.: 209 836-8908 Make/Model of Monitoring System: Beaudreau 522T Date of Testing/Servicing: 6/10111 H. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspected/serviced: Tank III'01.R®gu Tank%n. 02-plus o In-Tank Crauging Probe. Model: C] in-Tank Gauging Probe. Model: ❑ Annular Space or Vault Somor. model; ❑ Annular Space or Vault Sensor. Model: Q Piping Sump\Trench Sensor(s). Model: ❑ Piping Sump\Trench Sensor(s). Model: C3 Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector, Model: — q Mechanical Line Leak Detector. Model ❑ Plectronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Q Tank Overfill\High-Level Sensor. Model: _ Q Tank Overfill\High-Lovel Sensor. Model: ❑ Other(specify equipment type and model in Section t on Page 2). E3 Other(specify equipment type and model in Section H on Page 2). Tank IiD• 03-Prem Tank I>n• 04-Diesel _ Q in-Tank Gauging Probe. Model: Q in--tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor, Model: Q Piping Sump\Trench Sensor(s). Model; ❑ Piping Sump\Trench Sensor W. Model; 17 Fill Sump Sensor(s). Model: Q Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: p Electronic Line Leak Detector. Model: ❑ Ficeuonie Line Leak Detector, Model: Q Tank Overfill\High-Level Sensor. Made]: 13 'rank Overfill\High-Level Sensor. Model: [3Other(specify equipment type and model in Section E on Page 2). CI Other(specify equipment type 2nd model in Section E on Pago 2), Dispenser IQL 01.02 Dispenser ID• 03°04 Dispenser Containment Sensor(s). Model: Roaudmau Easu94 ® Dispenser Containment Sensor(s). Model: Ooadr E0310" ® Sheat Valve W. Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Fluat(s)and Chain(s). Dispenser ID' 05.06 Dispenser 110. 07-08 ® Dispenser Containment Sensor(s). Model: ewudmu 1103100.0 10 Dispenser Containment Sensor(s). Model: 50auAteeu E05190-0 2 Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Flerit(s),,nd Chain(s). Q Dispenser Containtnont Float(s)and Chain(s). Dispenser(D• 09-10 Dispenser ID; 11-12 N Dispenser Containment Sensor(s), Model: neaudmau 90$1004 a Dispenser Containment Sensor(s), Model: Beaudrftw E081MG 0 Shear Valve(s). 0 Shear Valve(s). 13 Dispenser Containment Float(s)and Chain(s). Q Dispenser Containincnt Float(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 Inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is Information(e.g.manufactures'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; (check aft that rrppty}: ❑ System set-up ❑ Alarm history report Technician Name(print):Bryan Lundeen Signature: Mfg.Ceti.#.: '�J ICC# 8001468-UT License.No.: 485184 Testing Company Name,• Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 630 Quinn Ave.,San Jose,CA 96112 Date of,resting/Servicing: 6110111