COMPLIANCE INFO 2007-2012 - Laserfiche WebLink

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MONITORING SYSTEM CERTIFICATION For Uve By all Jurisdictions Within the State ol'Calilbrriia JUN 0 �� A111/1oriry C•itecl. Clicilrler•6.7, Health curcl.Sc0 v Code; Chul-ler•16, Division 3, Title 33, Califbrid(t Code vf�ycrlar/cr1J1'olrs This forth inust be used to doetatl]ellt testing and servicing of monitoring equipment. A se arafe�Vi1� � •� must be prepared for each monitoring system control panel by the technician who perforans the work. A copy f t !tt rr t avided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regnlatuig UST systems within 30 days of test elate. A. Genera! Information Facility Name: �-- y C Bldg.No.: Site Address: C Ea-b+ Zipq`l-Za2- Facility Contact Person: , '��r1 Contact Phom No.:(,-O —I Make/Model of Monitoring SystenC, 14calex R&X:� Date of Testing/Servicing: QLa/-ft/DZ B. Inventory of Equipment Tested/Certified Check hie'Ippropriate 11!! es la iudirate specific ec ui rrlit!aIt ins aeeted/serviced: "rank ID: - Tank ID: � fn-Tank Gauging Probe. Model: Z In-Tank Garaging Probe. Model: �Amtulnr Space or Vault Sensor. Model 4407 fFiping linuiar Space or Vault Sensor. Model• ' 7 Piping Sump/Trench Sensor(s). Moclel: ,SUE--) Swap/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ll Sump Sensor(s). Model: ❑ Mechanical Line Leal:Detector. Model:. ❑ Mechanical Line Leak Detector. Model: Ll Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill 11-figh-Level Sensor. Model: ❑ Tank Overfill l Higli-Levet Sensor. Model: ❑ Other(s ecif e ui fent t•ie and model in Section E on Page 2). ❑ Other(s ecif e ui inent t re and model in Section E on Pae 2). Tank ID:-)I — Taink ID: ❑ In-Tank Gauging Probe. Model: M G ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: _ ❑ Annular Space or Vault Sensor. rvfodel: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: U Fill Sump Sensor(s). Model: Q Mechanical Line Leak Detector. Madel: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model., Other(s pecif e ui fent t,pe and model in Section E on Pae 2). ❑ Other(specify e ui fent t e and model in Section E on Pae 2). rDispensei nser ID: 3 �' Dispenser ID: penser Containment Sensor(s). Model:_ "� C,r ❑ Dispenser Contiinfent Sensor(s). Model• ar Valve(s). L1 Shear Valves). Dispenser Containment Float(s)and Claain(s). ❑ Dis tenser Containment Float(s)rind 0min(s). ID; U j 5 b Dispenser ID: penses•ContainmentScnsor(s). Model: Z ❑ Dispenser ContainmentSensor(s). Model: ar Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s), Dispenser ID: Dispenser ID: ❑ Dispenser Coastninment Sensor(s). Model: ❑ Dispenser Containnient Sensor(s). Model: I ❑ Shear Valve(s). ❑ Shear Valve(s), ❑Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). IYthe facility contains more tanks or dispensers,copy this form. I11a:ILI&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 it Plot Plan showing the layout of monitoring equipment. For arny equipment capable of generating such reports,I have ASO alttnClal'(l as Copy of the report;(check all drat rtpp/t): LI System set-up Alarm history ort Technician Name(print): Felix Ramirez Signature: Certification No.: License.No.: TTL 08-1740 ICC#5273 Testing Complaiiy Natne:AI l C?Ii�hp _'Lit •[ Phone No.:� 09 ) 7 �f Q 1 ! 2 S ire Address: �[ _t•}l a t"r -. _ Date of T esthtg/Servicing:)? f /bC1 Page I af3 0310 Monitoring System Certification D. Results of Testing/Servicing I