COMPLIANCE INFO_2016 - Laserfiche WebLink

Home Browse Search

Appendix VI JUN 0 3 2016 MONITORING SYSTEM CERTIFICATION - ®4 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 Facility Name: Pilot -Flying J #618 Bldg. No.: 1501 B Site Address: 1501 N Jacktone Rd. Facility Contact Person: Manager Make/Model of Monitoring System: TLS 350 Inventory of Equipment Tested/Certified City: Ripon Contact Phone No.: f 209 Zip: 95366 599-4141 Date of Testing/Servicing: 0 5/ 06 / 2 0 1 6 n ure sunny contams more tanKS or dispensers, copy mis Corm. mcwae rmormanon Tor every tanK ana arspenser at the tac iay. 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 Piot 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 C Alarm history report Technician Name (print): ISSaC Garcia Signature: Certification No.: 842806 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 / 06 / 2 0 1 6 Monitoring System Certification Page of 12/07 t,necK ine a ro nate Doxes io matcate s ecmc a ui meni insl iectea/servicea: Tank ID: vent Box Tank ID: Bio Shed ❑ In -Tank Gauging Probe. Model: N/A ❑ In -Tank Gauging Probe. Model: N/A ❑ Annular Space or Vault Sensor. Model: N/A ❑ Annular Space or Vault Sensor. Model: N/A )U Piping Sump / Trench Sensor(s). Model: 794380-208f794380-304 U Piping Sump / Trench Sensor(s). Model: 794380-208n9438e-304 ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Tank Overfill / High -Level Sensor. Model: N/A ❑ Tank Overfill / High -Level Sensor. Model: N/A ❑ Other(specify equipment t e and model in Section E on Pa e 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(specify equipment t e and model in Section E on Facie 2). ❑ Other(specify equipment t e and model in Section Eon Pa e 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). _j ❑ Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chain(s). in n ure sunny contams more tanKS or dispensers, copy mis Corm. mcwae rmormanon Tor every tanK ana arspenser at the tac iay. 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 Piot 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 C Alarm history report Technician Name (print): ISSaC Garcia Signature: Certification No.: 842806 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 / 06 / 2 0 1 6 Monitoring System Certification Page of 12/07