COMPLIANCE INFO_2014-2015 - Laserfiche WebLink

Home Browse Search

Appendix VI SUN 12 2015 MONITORING SYSTEM CERTIFICATION mN NM Nm_ 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 of Regulations 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 UST systems within 30 days of test date. A. General Information Pilot-Flying J#618 1501 Facility Name: y g Bldg.No.: Site Address: 1501 N Jack Tone Rd. City: Ripon Zip: 95366 Facility Contact Person: Manager Contact Phone No.:(209 599-4141 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 0 5 / 14/ 2 0 1 5 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: 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 t e and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2. TanklD: TanklD: ❑ 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(specifz equipment t e and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2L Dispenser ID: 26S Dispenser ID: 27M )❑ Dispenser Containment Sensor(s). Model: 794380-208 JE1 Dispenser Containment Sensor(s). Model: 794380-208 )C1 Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chains. Dispenser ID: 27S Dispenser ID: 28M JO Dispenser Containment Sensor(s). Model: 794380-208 Ki Dispenser Containment Sensor(s). Model: 794380-208 JO Shear Valve(s). J❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chains. Dispenser ID: 28S Dispenser ID: 29M )❑ Dispenser Containment Sensor(s). Model: 794380-208 JE1 Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chains. *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 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,I have also attached a copy of the report;(check all that apply): 81 System set-up ®Alarm history report Issac Garcia Technician Name(print): Signature: Certification No.: 842806 License.No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 1 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Seryicing: 0 5 / 14/ 2 0 1 5 Monitoring System Certification Page of 12/07