COMPLIANCE INFO 1995 - 2008 - Laserfiche WebLink

Home Browse Search

Mug MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California . ., �I,�,�(]y Authority Cited:Chapter 6.�41ealth and Safety Come; Chapter 16, Division.3, Title 23, California Co"lfe`bf UA This form must be used to document testing and servicing of monitoring equipment. A separate certrficatto ed for each monitorin system control anel by the technician who perforins the work. A copy of this form m �t� re Lank system ownerfoperator. 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: i~� Bldg.Na.; r� Site Address: City: Zip: Facility Contact Person: Contact Phone No.. ( � Make/Model of Monitoring System: 11,40L`i- Date of Testing/Servicing: lel B. Inventory of Equipment Tested/Certified Check the approeriate boxes to indicates ii#c a ui ment ins ected/serviceds Tan ID: Ta IID: lW7+e ,,,,,,��```Tank Gauging Probe. Model:j�,�4G�ti +t'c}zGe: LPpiping ln-"rank Gauging Probe. Madel: ular Space or Vault Sensor. Model:�c7L 5 /t�t t oot,5 nular Space or Vault Sensor. Model: Piping Sump f Trerrclr Sensor(s). Model: `' c+o= ,: ;�, Sump 1 Trench Sensor(s). Model: o ill'Sump Sensor(s). Model: — ❑,Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: s°r '� El Mechanical Line Leak Detector. Model: Ll 1Ck'ti I ' ❑ Electronic.Line Leak Detector. Model: Q Electronic Line Leak Detector. Model: ❑ Tank Overfill 1 Nigh-Level Sensor. Model: D Tank Overfill/Mgh-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). 0 other(specify ui went a and model in Section E an P_ a 2). Tank ID: '=. Tank ID: Ldp -Tann Gauging Probe. Model:f' tt. l�: t�"i ft "t9 ❑ 1n-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: PPZ1 ❑ Annular Space or Vault Sensor. Madel: Piping'Sump/Trench Sensor(s). Model: 7,4e:''Z,' i WOO i a^t3 Q Piping Sump/Trench Sensor(s). Model: C1 jF l Sump Sensor(s). Model: © Fill Sump Sensor(s). Model: 13'Mechanical Line Leak Detector. Model: LL: :,•iz yk_ L3 Mechanical Lure Leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: Q Electronic Line Leak Detector. Model: Q Tank Overfill/High-Level Sensor. Model: U Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Page 2). Q other(specify equipment a and model in Section E an Page 2). ty ss jjnser a �F4Dispenser ID: �.Q Dispenser Containment Serrsor(s). Model: spenser Containment Serasar(s). Model: i�hear Valve(s). ear Valve(s).lT Dispenser Containment Floats)and C}sain(s). s nser Containment Float(s)and Chain(s). Dispenser ID: -°'-. Dispenser ID: C �spenser Containment Sensor(s). Model: Z) Dispenser Containment Sensor(s). Model: Shear Valve(s). hear Valve(s). p"Dis nser Containment Float(s)and Chain(s). Lf Dispenser Containment Floats)and Chain(s). Dispenser LD: Dispenser ID: 0 Dispenser Containment Sensor(s)_ Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). UDispenscr Containment Floats)and Chain(s). 1 0 Dis enser 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 -1 certify that the equipment identified in this document was inspectediserviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' chec ) necessary to verifv that this information is correct and a Piot Plan showing the layout of monitoring eq cut- For any equi 'ent capable of generating such reports,1 have also attached a copy of the report;(thrall that apply): Ly System set-up U Al isto re Technician Name(print): S t =' �'vtJ Signature: ^--�— Certification No.: f License.No.: Testing Company Name: tE; :Y►•f-'1 7=nt'� ei 1, —— Phone No_:� '�' L'LC� ��el` V Date of Testing/Servicing: I Site Address: /''L':• 1` L's`z AC,t-*01- Page 1 of 3 {N01 Monitoring System Certification