COMPLIANCE INFO_2008-2018 - Laserfiche WebLink

Home Browse Search

70 . RE Cap CERTIFICATION V Ef- i� MONITORING SYSTEM � For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code dP 2 1 LO(® Regulations ENViR0pjpI,, E T 14EALT This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared f /E P��I f %�`"� p (�C t each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ' � -' i � . _ L ) 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 hi.—MIRAMAR ENT VALERO Bldg. No.: Site Arrrirarc 1605 S EL DORADO ST City: STOCKTON CA Facility Contact Pargnn ANGLE Contact Phone No.: Make/Model of Monitoring System: VEEDER ROOT TLS 350 B. Inventory of Equipment Tested/Certified r�Rwe, s6.., -. ,yam hnv®o ♦r. incline!® cnar•i4ir .� �inm®nF i or*orl/enrvirarl• Zip: Date of Testing/Servicing: 5/18/2010 Tank ID: 87 oct _ Tank ID: 91 oct ® In -Tank Gauging Probe. Model: mag 2 ® In -Tank Gauging Probe. Model: MAG 2 ® Annular Space or Vault Sensor. Model: 420 ❑ Annular Space or Vault Sensor. Model: SPLIT W 87 ® Piping Sump / Trench Sensor(s). Model: 205 ® Piping Sump / Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector, Model: Id 2000 ® Mechanical Line Leak Detector, Model: LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging 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). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: _ ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1-2 Dispenser ID: I� ® Dispenser Containment Sensor(s), Model: 001 ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 3-4 Dispenser ID: ® Dispenser Containment Sensor(s). Model: 001 ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5-6 Dispenser ID: ❑ Dispenser Containment ® Dispenser Containment Sensor(s). Model: 001 Sensor(s). Model: ® Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). 'If the facility contains more tanks or dispensers, copy this form. Include information for every tank ana oispensef at the taClllty. C. Certification - I certify that the equipment identified in this document was inspected/serviced 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, 1 have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): DAVE WINKLER Signature: �4��____ 7 Certification No.: 5263373 -UT License No: 08-1739 'Testing Company Name: AFFORDA_-TEST Phone No. (209) 744-0113 Testing Company Address: 416 2 STREET GALT, CA 95632 Date of Testing/Servicing: 5-18-2010 Monitoring System Certification Page 1 of 4 2/21/07