Laserfiche WebLink
- MONITORING SYSTEM CERTIFICATION <br />Authority Cited, Chgter' 6,7, 17'or Ura BSc All <br />oAriElc rions `��r`!in the Sfule 4-C'al forelia <br />P 16, DIvL41nyt 3. Tlr1e -73, CAliforruu Cude Oj'Reguldtjons <br />This foml must be wicd to docurilLnl te!i1ing. and servicing of rnOnjwrine, equiprncnr. A 'L to c till tion r ort •t hL n n <br />Wtir<tn1111 `3 m cont UI rule! b the tech[lician who pertorrny the wurk. A CO of <br />for ac <br />�� -P Y AY this form must be provided to zh< tank ayswm owuedopet�rac <br />The ownez/Uperaror must su6m�r s, copy of chi: Form to the luuul ngency %;gula[igg UST Syswxns within 30 days oft daia- <br />A. General Information <br />Paciil;y Name:— 1 - <br />Site Address: No-: <br />/ �- <br />Fticiliry con[ttct per$r nCity; — Zip: ^�W <br />Make/Mu Cun#act Phone No.: } <br />del Of Mbnllprlrig SySCC17t: _ <br />Date of Testing/Sorviei.gg: f O —n -tom <br />S. Inventory 9f �qui�pil>aeJl[,t TestecllGt'rt>llied <br />- 1i me a ru r1Atr bpxes tU igdiL'xtp s ecitlC a tri It1CLr in9 eCCed/SEY►'i <br />Tank- ID, <br />In -Tame Gaugia4 Probe. <br />(] In -Tank Gxlu�ing Prub,. <br />NlodcL <br />Arulular Spaoc or Vault Scrtsur, <br />lvlodel:�-` <br />Zpiping Sump /'.french Scnsor(s). <br />Model; ` <br />❑ Fill Sump Senwr(s). <br />Model: <br />Me(:hatlical Line Leak: 1)errrtor. <br />Moeirl: <br />L1 ficctrunic Line Leak Detec[or. <br />Model: -� <br />❑ Tank- Overfill / !lige-Level Sciilior. <br />Model; <br />❑ Qther (spanily equipnjent type wid ,Model $t Seutioll E on page ?), <br />Tani: fl); <br />❑ In- %Ilk Cauziazo Prnha <br />lVtodtl; <br />❑ Annular Space or Vault Scilsor. <br />tviodel: <br />Piping Surnp / Trench Sensur(s). <br />Nludcl: ---- <br />El Fill Sump Sall or(s). <br />Model: <br />❑ Nleuhtuticl4 Line Leal; 001CCtor, <br />]Model: <br />❑ Elecnoniv Line Leak Delccrur. <br />Model; <br />❑ Tirol+ Uveffill / High-Lcvel Sensor, <br />Model: <br />❑ Other (specif(cquipmcnt We and model in Section <br />Di>pcnsar Cpn[ainment Sensor{s), <br />E un pale 2). <br />Diapenscr Ill: 1 <br />Model; <br />z4zispCnycr COD IalrunKJ1T Sensor(s), <br />lvludel:'-My <br />❑ Shear Vallva(s). <br />�`7fYr <br />Cj i ispcnser (:ontainnlent FJoo[(s) turd Chain(s), <br />Aispenser <br />Dlopewrr Contaurmrnt Son;pr(s). <br />ivlpdCl: <br />(] Shear valvgs). <br />Q Di�pcnser ContaitlLltent FluaL(s) and <br />Chain(s). <br />Dispenser 1JD; <br />l� Dispenser Cont;tinment ycnsor(s). Model: Dispenser 1b: <br />5ihee2 valvc(s). ❑ Divcn3c,- CuuL•liIDUent yensor(s). Model: <br />❑ 1)ispcnser Containment Floats) and Chairi(s). ❑ Shear Valvc(s). <br />DisPcnser "ll' IhC t£tl lllry CpJ'llaln5 fnUT2 [fln(S or dispaal erg, copy this luml. lnciudc iljfjr=Mt ipr every tcllkrimcrit Fmloai{ds�p an(hc facility- nsar <br />C. Cidell s. t10n - 1 certify that the equipment identified in this document was iaspectedlserviaed in accordance with the mauufacturers' <br />guidelines. Attached to this Certi et+iiott is this <br />(e-g- nianuracturers' ehecklilts <br />current and a Plot Plan showing the layout of fnonitoriq e ) accessary to verif <br />attached a copy of [he report: (cheek all rhul p 1, . g qutpmen[, bot ally eq ment capable of eneratiny that this information (s <br />Pp])• $4 System set-upg such r orts, 1 ha a also <br />Technician Name (print): Ton Fontana AIArm ftiscur port «�� n <br />signature: <br />Certiiicadon No.: V -R A23686 I.C.C. 5289227.0 -T. �o►r�. <br />Testlno Company Nan, U.S. T. Com liant;e Test! Inc Licclise- No,: "A" Gen.En . 846288 <br />"Ceding Company Address: P.O. Box 580 Ceres CA 953f17 ^' Phone No --.(209 595-44$9 �` <br />Uare oFTesting/Servicirl,g: <br />Page 9 of 3 <br />-ratllc 11); C <br />In -Tame Gaugia4 Probe. <br />Model: <br />ae❑ <br />r�,tLutulur Space or vault sensor. <br />_ <br />Nlodtl: <br />Pipigo Sun'Lp / Trench Scnsor(s). <br />Model'" <br />❑ Fill Sutnp Sensor($), <br />Wrim: <br />J6Mcchtlnical Liuc Leah;: Detector. <br />Model, 1 <br />[] Electronic Line Leal, Detector. <br />Model- <br />[] Tank overfill / HiQI1-Level SC[Lypr. <br />❑ Other (specify cquipmenl and <br />Model. <br />We <br />model in Secrion Eon Pagr 2), <br />Tank ID: <br />Li hl-TAft: Gauging Probe. <br />I <br />Model; <br />❑ Annular Space Or Vault Sensor. <br />Model; <br />❑ PipinA Sunlp / Trench Scru=(a). <br />Fill Sunlp S=Ogs). <br />ModcL <br />❑ M=haniCal Linc Leak Deector. <br />Model; <br />Model: <br />❑ Elcctrotlit; Linc Leal: Iactcclor. <br />Model: <br />❑'i'slkOverfill/ High -Level Sensor. <br />Model; <br />(] Other (9XC1fy equipmenr --and model in Seclinn F on P WHe -), <br />Dispenser ID:1111111191 1!!: 1 <br />Di>pcnsar Cpn[ainment Sensor{s), <br />i� 311car Volvo($), <br />Model; <br />❑ Dispenser Conuairunent Floui(s) and Chaia(s). <br />Dispenser B]; " I .- <br />o&Dispenser Conlainnlent Sensor(s), <br />Model; <br />❑ Shmr Valvas <br />L� Dispenser Conte l meal Float(s) Md. <br />Chain($), <br />90/Z0 39Vd <br />6003 SV9 3NO d <br />Rev (2/I ) <br />9LSILEE860Z 6580 800Z/LT/0T <br />