COMPLIANCE INFO_2016 - Laserfiche WebLink

Home Browse Search

i . Appendix VI JUN 0 3 2016 MONITORING SYSTEM CERTIFICATION 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 g Pilot -FI In J #618 Bldg. 1501 Facility Name: y g. No.: Site Address: 1501 N Jacktone Rd. Facility Contact Person: Manager City: Ripon Contact Phone No.: ( 209 Zip: 95366 599-4141 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 0 5 / 04 / 2 0 1 6 B. Inventory of Equipment Tested/Certified Check the annrnnrintP hnYPs fn indiratP snerifir. Pni inment insnP&Pd/servfred- Tank ID: T1 Diesel 20K Tank ID: T2 Diesel 20K r❑ In -Tank Gauging Probe. Model: 847390-109 )❑ In -Tank Gauging Probe. Model: 847390-109 X3 Annular Space or Vault Sensor. Model: 794380-303 >❑ Annular Space or Vault Sensor. Model: 794380-303 .0 Piping Sump/ Trench Sensor(s). Model: 794380-208 )e Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A )€I Mechanical Line Leak Detector. Model: Fx1VD >0 Mechanical Line Leak Detector. Model: VMI LD2000 ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A x❑ Tank Overfill / High -Level Sensor. Model: OPW Flapper xp Tank Overfill / High -Level Sensor. Model: OPW Flapper ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Page 2). Tank ID: T3 Diesel 20K Tank ID: T4 8712K )€] In -Tank Gauging Probe. Model: 847390-109 )U In -Tank Gauging Probe. Model: 847390-107 TC] Annular Space or Vault Sensor. Model: 794380-303 C Annular Space or Vault Sensor. Model: 794380-303 jo Piping Sump/ Trench Sensor(s). Model: 794380-208 x❑ Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A �] Mechanical Line Leak Detector. Model: VMI LD2000 Hp Mechanical Line Leak Detector. Model: STP MLD ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ] Tank Overfill / High -Level Sensor. Model: DPW Flapper xU Tank Overfill / High -Level Sensor. Model: DPW Flapper ❑ Other(specify a ui ment type and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: 1-2 Dispenser ID: 3-4 /E7 Dispenser Containment Sensor(s). Model: 794380-208 'f7 Dispenser Containment Sensor(s). Model: 794380-208 'E] Shear Valve(s). n Shear Valve(s). ❑ Disenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 )E] Dispenser Containment Sensor(s). Model: 794380-208 )E] Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). TE] Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 TE] Dispenser Containment Sensor(s). Model: 794380-208 TE] Dispenser Containment Sensor(s). Model: 794380-208 TO Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chain(s). -it me Tacirty contains more [anKS or arspenserS, copy Ins Torm. mcivae InTarmauon Tar every tanK aria aispenser at the Tdcmly. 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 verity 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): ® System set-up ® Alarm history report - _;z_ Technician Name (print): Issac Garcia Signature: Certification No.: 642806 License. No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 0 5 / 04 / 2 0 1 6 Monitoring System Certification Page of 12/07