COMPLIANCE INFO 2001 - 2009 - Laserfiche WebLink

Home Browse Search

Monitoing System Certific Bion 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 s form must be used to document testing and servicing of monitoring equipment. Separate certifications or reports must be Wed for each monitorin stern controlanel by the technician who perfroms the work. A copy of this form must be pry,. ed 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. ... General Information acility Name: Stockton,CA Switch Bldg: SET Job#: T7 036784 ite Address: 3807 Coronado Ave City I State Stockton CA Zip: 95204 acility Contact Person: Jay Lemes Contact Phone No.: 209-937-5800 lake 1 Model of Monitoring System: Date of Testing/Servicing: 9/12/1006 B. Inventory of Equipment Tested or Certified Check the appropriate boxEs to indicate equipment inspected or serviced-, Tank ID T-2 UST Diesel Tank ID T4 AST Diesel Mag I ® In Tank Gauging Probe Mag 1 In Tank Gauging Probe ago CK Annular Space or Vault Sensor U2 ® Annular Space or Vault Sensor 208 Piping Sump/Trench Sensors) T ® 08 Piping Sump I Trench Sensors) NIA ❑ Fill Sump Sensor(s) WA ❑ Fill Sump Sensor(s) PLLO WA Mechanical Line Leak Detector ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Electronic Line Leak Detector ® Tank Overfill/High-Level Sensor 1.3 7 300C ® Tank.Overfill/High-Level Sensor 1i3 3DCG Other(specify equipment type and model in Comments. ❑ Other(specify equipment type and model in Conunents. Tank ID Tank PD ❑ In Tank Gauging Probe ❑ In Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor Piping Sump/Trench Sensors) i _ ❑ Piping Sump/Trench Sensors) Fill Sump Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Mechanical Lane Leak Detector ❑ Electronic Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill/High-Level Sensor ❑ Tank Overfill/High-Level Sensor ❑ Other(specify equipment type and model in Comments. ❑ Other(specify equipment type and model in Comments. Dispenser ID NIA Dispenser ID MA ❑ Dispenser Containment Sensor(s). Dispenser Containment Sensor($). ❑ Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID Dispenser ID ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s). ❑ Shear Valves(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID _ Dispenser ID ❑ Dispenser Containment Sensor(s). ❑ Dispenser Containment Sensor(s). ❑ Shear Valves(s)_ ❑ Shear Valves($). ❑ Dispenser Containment Floats)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 manufacturers' guidelines.Attached to this certification is information(e.g.manufacturers'checklists)to verify 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 Technician Name(print): Fabian Gomez Signature: �. Certification No.-. A24225 W License No.: Testing Company Name: Shirley Environmental Corporation Phone No.: (909)476-7443