COMPLIANCE INFO 1988 - 2006 - Laserfiche WebLink

Home Browse Search

MONARING SYSTEM CERTIFATION 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: :tjOyS T U'S Site Address: %G � Y A rm V G' of + Facility Contact Person: (r 16r, Make/Model of Monitoring System: �'- JGeder op'�- Tls 30oC- B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Bldg. No.: City: S+o--_kf-tJ Zip %U6 Contact Phone No.: QA2�1 ) qAr- OJ/2- -eA-f_V3 Date of Testing/Servicing: 8 - i.-) -,o3 Tank ID: 1 .S Tank ID: ❑ In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: (.'Annular Space or Vault Sensor. Model: S O - 920 ❑ Annular Space or Vault Sensor. M (, P ping Sump / Trench Sensor(s). Model:79qM IZO ❑ Piping Sump / Trench Sensor odel: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Li Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electro ' ne Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ jpkl5verfill / High -Level Sensor. Model: ❑ Other s ecift e] ui ment tv e and model in Section E on Page 2),they s eeifv e ui ment t e and model in Section E on Pae 2). - .Tank Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model• ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. el: ❑ Piping Sump / Trench Sensor(s). ❑ Piping Sump / Trench Sens Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s Model: ❑ Mechanical Line Lea ector. Model: ❑ Mechanical L' eak Detector. Model: _ ❑ Electronic Li Detector. Model: ❑ Electro ' ine Leak Detector. Model: ❑ Tanill / High -Level Sensor. Model: ❑ T Overfill / High -Level Sensor. Model: t er (specify equipment a and model in Section E on Pa e 2). Other (s eci a ui mea and model in Section E on Pae 2). Dispenser ID: lb 1 11 enser 1D: (-715ispenser Containment Sensor(s). Model: e7 q�jO :320 �Z ❑ enser Containment Sensor(s). Model: 0—Shear Valve(s). ❑ Shear Ive(s). ElDispenser Containment Float(s) and Chain(s). ❑ Dispenser ntainment Float(s -and Chain(s). Dispenser ID: -'dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containm Sensor(s). Model: ❑ Shear Valve(s). C3Shear Valve(s). ❑ Dispenser Containment Float(s) and S. 13Dispenser Containment Float nd Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Co ent Sensor(s). Model: ElDispenser Containment Sensor(s). Mo ❑ Shear e(s). ❑ Shear Valve(s). enser Containment Float(s) and Chain(s). ❑ Dispenser 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 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): ((System set-up (Alarm history report Technician Name (print): LEE A. WILLIAMS Signature: Certification No.:—% ' 0 Z vim$ License. No.: 03160 Testing Company Name: Stockton Service Station Equipment Co., Inc. Phone No.:(209)464-8333 Site Address: Date of Testing/Servicing: Page 1 of 3 Monitoring System Certification 03/01