COMPLIANCE INFO_2008-2011 - Laserfiche WebLink

Home Browse Search

Work Order: 2267813 Monitoring System Equipment Certification For Use Lav A11.turisdictionr 071hin The State gl'Cal yf,rria Authority Cited: Chapter 6.i, Health and Sqly Code; Chapter 16, Division 3, Title 23, Cahlor�7ta Code o/'Regulations This form must be used to document testing and servicing of monitoring equipment. A semarate certit!+cati�n or report tnust_l>e 2renared for each inonitorint?system control panel, by the technician who performs the work. A copy cif this form must he provided to the tank system owner/operator. The owner/operator must submit a cope of this form to the local 4gency re(Agulating UST system within 30 days of test date. A. General Information Facility Name: Shell 136187 Blida. No.: Site Address: 2375 W.Grant Line I-205 Citv: Tracy; CA "Lip: 95376 racility Contact Verson: Ott cc-r1 Contact Phone No.: (209)836-8908 Make!Model of Monitoring System: V/l2 Simplicity k 1, S r Date of-Testijmg/Servicing: -71,10,-1 _ B. Inventory of Equipment Tested/Certified (:'heck the appropriate butes to indicate specific equipment inspected/serviced: Tank ID, Tank ID ❑ In-Tank Vauan g Probe. model: ❑ In-Tank Gauzimt rc be. NlodcL { ❑ Annular Spae(!or Vault Sensor. liodcl. ❑ Annular Space or Vault Sensor Model pa—Piping Sump 1 Tench Sensor(s). Model: < ❑ Piping Sump t Trench Sensor(s). P tudc1: ❑ Pill Sonp SeRSOr(s). Model: ❑ Fill Sump Sensor(s). Model. M _ ❑ Mechanical tine Leak Detector Model: ❑ Mechanical Linr. �c I.eak Detector IodcC ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Nlodcl: j p Tank Ovcr ill Itigh-Level Sensor. Niodel: C] Tank Overfill Ili..gh-Leve!Sensor. Model:,R iJ- Other(specific cquipment type and model in Section E on Page 2). ❑ Other(speeif}equipnnent type and mode!in Section E on Page 2). --— Tank ID- Tank ID• ❑ In-]Rnk Gauging Probe model. ❑ In-'Tank(.rouging 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). t lode( �) ❑ I ill sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Modcl:_ ❑ Mechanical Line Leak Detector. Model:_ ❑ Mechanical!.ins Leak Detector, Model: ❑ Flccuomc Eine Leak Detector. Model ❑ Flectt'ooic Linc!.emk Dctectot. f lodcl. _ ❑ I ank Overfill%High-Level Sensor. Model. C3 "rank Overfill l High-Level Sensor. Muck!: ❑ other(specify equipment type and model in Section'c on Page 21 ❑ Other(specify equipment type and model in Section F.on 11age Z). ,I 1>ispenser Il)' S l¢ Di enser ID7=,-4 Dispenser Containment Sensor(s) Model: )S /� Dispenser ContainmentSensor(sj. Modcl' c1S /tJi� ❑ Shear Valve(s). ❑ Shcar Valve(s) ILD Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). II Dispenser IQL Db&> Dispenser IU;_ /= _ ipenser Contalrun nt Sensor(s). Nlodel: Dispenser Containment Sensor(s;, ilo cl: _J� (—�� ❑ Shear Valve(s) ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID;- Dispenser IDi II ❑ 1)ispenaer Coutatnmcnt Sensor(s). Model: ❑ Dispenser Cuntainntent Sensor(s). rLnicl. ❑ Shear Valve(s). ❑ Shear Vatic ❑ Dispenser Containment Float(s)and Chain(;). ❑ Dispenser Containment Phut(s)and Crain(>). l"If the facility contains more tanks or di.spen;ers,copy this flan(.Include infi)rmation Ito every tank and dispenser at the racilitN C.Certification- t certify that the equipment identified in this document was inspected/serviced in accordance tcitlt the manufacturer's guidelines. Attached to this Certification is information(e.g.manufactures'checklists)necessary toiverify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of%enerating such reports,I have also attached a copy of the: (check all that apply)., (�Systcm sct-ap Afarm history report Technician Name(print): Bryan Lundien Signature: i Mf-,.Cert.Y.: ICC# License.No.: 485184 Testing Company Name: SerV.Sts.Sys. Phone No.: (409)971-2445 Testing Company Address: 680 Guinn Ave.,San Jose CA 95112 Bate of Testin;o;Scrvicing: 7/l.`0, Tanknology Inc. 8501 N.MoPac Expressway,Suite 400,Austin,Texas 78759