COMPLIANCE INFO_2016-2018 - Laserfiche WebLink

Home Browse Search

Appendix VI (copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION €� Vit' 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 Cade 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: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 Bldg. No.: Site Address: 2360 W GRANTLINEI-205 OFF RAMP City: TRACY Zip: 95376 Facility Contact Person: CHANDRA Contact Phone No.: 209-830-9917 Make/Model of Monitoring System: Veeder Root TLS -350R Date of Testing/Servicing: 3/3/2016 B. Inventory of Equipment Tested/Certified 1I..,..1... --.....i.. ;-- k--- -M, en.An.,.enf in .n .A 1e An A - Tank ID: Tank ID: r In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model:Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model•Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: F1,Tank Overfill /High -Level Sensor. Model: i Other(specify equipment t e and model in Section E on Page 2). r7 Other(specify equipment a and model in Section E on Pace 2). Tank ID: Tank ID: r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r" Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Page 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s). Model: 784380-352 Dispenser Containment Sensor(s). Model: 784380-352 Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: W, Dispenser Containment Sensor(s). Model: 784380-352 17, Dispenser Containment Sensor(s). Model: 784380-352 Shear Valve(s). 17, Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s). Model: 784380-352 17, Dispenser Containment Sensor(s). Model: 784380-352 Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). -it the racluty contains more tanKs or aispensers, copy this Torm. inauoe imormaaon Tor every tanK ana dispenser at the Tacmty. 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): Pr System set- up Pr Alarm history report Technician Name (print): Certification No.: B4536 Nicolas Poblano Signature: License. No.: 743160 Class'A' Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Phone No.: (800) 800-4633 Page 2 of 4 Date of Testing/Servicing: 3/3/2016 12/07