COMPLIANCE INFO 2008 - 2012 - Laserfiche WebLink

Home Browse Search

P11 May 21 02 10:24a Eli' Iv Contractors Inc 209461F'342 p.2 — -- _ — Cf` d'u'n LL, A 01 CALAVERAS ENV ($ALTH 97./02/1995 03:27 2097546722 TION / =-- �p��T G STEM CER`I`IFICA MpTORIN SY r le<rd..t:citoxs Al c.. .- Fc; �.s• ery Code: Chn res 16. Division 3. Tarte 13. California code 11.1Rcgulanons P ,tulhoriry Cited' Chapter 6 7. Health and Saj than One c ui mit- if more f ent testing and servicing of monitoring tl p mu tgd 'T'his form must be used to do is i oc to certificaho must be anel is installed at the facility, a co of this form monitoting system control p and by the technician who performs the work' A of this form to the local each mon tori S cratoT- The owner/operator must submit a copy owncrlop crions are printed on the back of this page - provided to the tank syst� ns withw 30 days of first date. Instructions agency Tegulating UST sy A. Geaerall:forltion Factliry Fzciliry Contact Person: Mal;e/Mode) of Monitoring Sysleul." B. Iaventoty of-q,,ipm¢a''t estedlCertifled Check thea ro date boxes to tnw" - - Tank 1D: `6 7 Model: f —� fl to -Teak Gauging Probt r t7 Anular Space of V wit Smso Q PipmB S reach Sens -(Z) . Model: �--- O fill sump Sen+o+(=)- Model: 0 Mechanical Line Leak Dettanr. Model: cr Electronic Line Leak Deteor. Model da A a Tank Overfill / High -Level Sensor. nsModel' ❑ Dispenser Coanintnenen t Ssor( )• O Shear ValVe(s)- Flow(s) and Cltaat(s). 0 Dispenser Containment t and model in Section E on O Orher ( ui Tank ID: ModcL 0 In -Tank Gauging 0 Atmular Space or Vault sensor. Model: 0 Piping sarnprTreneh S -S -(s)- Model: Model: Q Fill Sump Sensor(s). 0 Mcchamcai Line Leak Detector. Model: AElemenic Line Leak Detector. ModcliiM 0 Tank <).aftll / liigh-Level SenFor — Cl Dispenser Conulntnew Seo or(s ) Model: Cl $hear Valve(s) Q Dizpcnser Conwinmcat Flouts) and chain(s). 0 Other (s i ui and model in Section E o ,y Bldg. Zip' City: Contact Photac NO.: G:�) 1)4tc of Tcsung,Serviciag= astao I � Tank ID' Probe Luong - 0 Annular SP11c Or Vault SCrlinr- model: Q Piping Sump Trench Sensot(s). Model: 0 Fill Sump serzor(s)- eehanical Line Leak Detector. 'Chani vtodcl: Model- Model / g _ l9 ctrooic Linc Leak petect, 0 Tw& Ovcrftll ! liiglt l-evet Sensor Model 0 DispcnwrConUuMneAt Sensor(s). Model. a Shear V&lvc(z)• Q Dispet ser Containment Floats) and Chwn(s)- in Section E on Paec:!)- )- s t and mode! 0 Odra cif c ui Tank ID: — a in -Tank Gauging Probe Model: D Annular Space or Vault Sensor. Model: Model' 0 Piping Sump/Trench S"sor(sl. Model: T 0 Fill Sump S --(S). Model M,cchanical Line Lcak Octeccor. Electronic Line Leak Detector. l row Sensor. Model-'— U Tank Overfill / High -Levet Cntttaintttent Sensors) Model: (] Dispenser ❑ Shear V1lYe{9)- 0 Dtspcnz;a Containmcrat Flou(a) and Chain(s). and model to Section Eon Pale 3) - 2). after s i vi ent type in accordance %Yith C. Certification - I certify that the equipment identified in this document ares t afacturcrss,checklists) tucessaryho manufacturers' guidelines. Attached to this Cerslllcatiou n information (•B• verify that [bis infortnadon is correct and a Site Plan showint the layout of monl(oring equipment. For any equipment verifycapabt a gbis i ttiag such reports, l have also aatehed a copy of the (check air that apply): O System set-up report; _-U-,Aaitnzw ` report. Tochnicitn )\lase (print )/��catAic. No: 4717 J «r� �,_�— Phone No.: �O' — c3 7 Testing Company Name: otos" pace -- ' CALM41