COMPLIANCE INFO_2016-2017 - Laserfiche WebLink

Home Browse Search

Appendix V1 JM MONITORING SYSTEM CERTIFICATION For Use By A#Jurisdictions Within the State of Calffomia Authority Cited. Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23, Callforin la Cade Regulations -1 _1 I Ir � 11 1-1 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. ltv: Ripon, CA. 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 /0 3 2 0 1 7 B. Inventory of Equipment Tested/Certified Check the roprlate boxes to Indicate!MIfic,nuipment Insl ected/serviced: Tank ID: Tank ID: 0 In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: Ei Annular Space or Vault Sensor. Model: o Annular Space or Vault Sensor. Model: El Piping Sump/Trench Sensor(s). Model: o Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: [I Mechanical Line Leak Detector. Model: 11 Electronic Line Leak Detector. Model: Ei Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Other(specify 2quipment type and model in Section E on Page 2). 0 Other uipment bg2 and model in Section E on Pa Tank ID: Tank ID- 0 In-Tank Gauging Probe. Model: ii In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: o Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s). Model: [i Piping Sump/Trench Sensor(s). Model: 11 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: o Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: o Tank Overfill/High-Level Sensor. Model: 0 Others 2gulMent and model in Section E on Page 2). Ei Others 29U' Merrt b22 EW model in Section E on PM 2). Dispenser ID: 26s Dispenser ID: 27M C Dispenser Containment Sensor(s). Model: 794380-208 Ki Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). KA Shear Valve(s). 0 DIMenser Containment Float(s)and Chaln(s). El Di ser Containment Float(s)and Chain(s). Dispenser ID: 27s Dispenser ID: 28M JE Dispenser Containment Sensor(s). Model: 794380-208 xi Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). x] Shear Valve(s). 0 Dispenser Containment Float(s)and Chaln(s). 0 Dispenser Containment Float(s)and Chaln(s). Dispenser ID: 288 Dispensw ID: 29M C Dispenser Containment Sensor(s). Model: 794380-208 xj Dispenser Containment Sensor(s). Model: 794380-208 le Shear Valve(s). N1 Shear Valve(s). El g!§p2nser Containment Float(s)and Chains 0 Dig!2mar Containment 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 manufacturers' guidelines. Attached to this Certification Is Infoirmadon(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 aWy). V System set-up 9 Alarm history report Technician Name(print): James Blaine Signature: Certification No.: V-R#-B43163 / ICC#-6469775 License. �i8O4431 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 Certification Page of 12107