COMPLIANCE INFO_2016-2017 - Laserfiche WebLink

Home Browse Search

Appendix V1 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Calffibmia Authority Cited. Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Tft' 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 LIST systems within 30 days of test date. A. General Information Facility Name: _ Flying J#618 Bldg.No.: Site Address: 1501 N.Jack Tone Rd. City: Ripon, CA. Zip: 95366 Facility Contact Person: Manager Contact Phone No.:(209 ) 599-4141 Makallodel of Monitoring System: TLS 350 Date of Testing/Servicing:0 5 /0 3/ 2 0 1 7 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate sp2cific 2guipmenti nsl ilacted/serviced: Tank ID: T5 91 12k Tank ID: T6 Auto Diesel NJ In-Tank Gauging Probe. Model: 847390-109 *j In-Tank Gauging Probe. Model: 847390-109 $U Annular Space or Vault Sensor. Model: 794380-303 xrj Annular Space or Vault Sensor. Model: 794380-303 X] Piping Sump/Trench Sensor(s). Model: 794380-208 10--1 Piping Sump/Trench Sensor(s). Model: 794380-208 0 FIN Sump Sensor(s). Model: N/A 0 Fill Sump Sensor(s). Model: N/A X] Mechanical Urve Leak Detector. Model: VMl LD2000 x3 Mechanical Line Leak Detector. Model: FX1VD 0 Electronic Line Leak Detector. Model: N/A Li Electronic Line Leak Detector. Model:_wA .0 Tank Overfill/High-Level Sensor. Model: DPW Flapper ri Tank Overfill/High-Level Sensor. Model: DPW Flapper 0 Other uipment type and model in Section E on Page 2). Ei Others uipment type and model in Section Eon Pa 2). Tank ID: T7 Waste Water 1k Tank ID: Kj In-Tank Gauging Probe. Model: 847390-107 o In-Tank Gauging Probe. Model: )c Annular Space or Vault Sensor. Model: 794380-303 0 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: N/A o Piping Sump/Trench Sensor(s). Model: 9_� Fill Sump Sensor(s). Model: 794380-208 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: NIA Ei Mechanical Line Leak Detector. Model: 11 Electronic Line Leak Detector. Model: NIA [i Electronic Line Leak Detector. Model: je Tank Overfill/High-Level Sensor. Model: 847390-107 o Tank Overfill/High-Level Sensor. Model: 11 Other(spec!!y 2gy!PE!ent and model in Section E on Page 2). 11_Other u!p!pent type and model in Section E on Pae Dispenser ID: 13 Dispenser ID: 14-15 )U Dispenser Containment Sensor(s). Model: 794380-208 '� Dispenser Containment Sensor(s). Model: 794380-208 � Shear Valve(s). Nj Shear Valve(s). El Dispenser Containment Float s�and Chaini(s). Ei DIMNnser Containment Float(s)and Chain(s). Dispenser ID: 16 Dispenser ID: 19M 16 Dispenser Containment Sensor(s). Model: 794380-208 � Dispenser Containment Sensor(s). Model: 794380-208 -n Shear Valve(s). � Shear Valve(s). 11 Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). Dispenser ID: 199 Dispenser ID: 20M 2C Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 794380-208 -K] Shear Valve(s). Kj Shear Valve(s). ii Disp2user Containment Float(s)and Chains 0 Dispenser Containment Float(s)and Chain(s). *ff 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 inspectod/serviced In accordance with the manufacturers' guidelines. Attached to this Certification Is Information(e.g.manufactuirers!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 aWy). 9 System set-up ro Alarm history report Technician Name(print): James Blaine Signature: Certification No.: V-R#-843163 I [CC#-8469775 License. 1 3 44 :i860�a Testing Company Name: Jones Covey Group, Inc. Phone No.:(909 ) 972-7581 Testing Company Address. 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing:0 5 /03/ 2 0 1 7 Monitoring System Cerdftatlon Page of 12J07