COMPLIANCE INFO 2002 - 2007 - Laserfiche WebLink

Home Browse Search

W, IIONITORIN G SYSTEM CERTIFICATION For Use By All Jurisdictions Witr.in the State of California Authoriryy Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be orepared fpr each monitorine systern contra! panel by the technician who perforans the work. A copy of this form must be provided to the tank system owner/operator. The ownerioperator 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: Plru) #4RW Site Address: Ro t. AArCl1nA City: Bldg. No.: Zip: Facility Contact Person: u 1,,Contact Phone No.: ( ) , IAe' Make/Model of Monitoring Svst_ n: W�m 5�3� Date of Testing/Servicing: IZZ. '0_ B. Inventory of Equipment Tested/Certified Tank ID: Tank ID: Cl 1Lt-Tank Gauging Probe. Model: O In -Tank Gauging P4,bc. Model: Annular Space or Vault Sensor. Model�xiy'.�A nnular Space or Vault Sensor. Model: .� Piping Sump / Trench Sensor(s). Mode�'�8 APiping Sump /Trench Sensor(s). Model,. -20R5l ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: 9 Electronic Line Leak Detector. Model: CT, C.P.T. A& Electronic Line Leak Detector. Model: v • CPT Cl Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify eouipment tv a and model in Section E on Pace 2). ❑ Other (specify a uioment type and model in Section E on Pa,c 2), Tank ID: b Tank M: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gau.ning Probe. Model: Annular Space or Vault Sensor. Model- -R43 Fk)-40ck D -4 O Annular Space or Vault Sensor. Model: ';ILPiping Sump / Trench Sensor(s). Modelo ='fib ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model -M ❑ Fill Sump Scnsor(s). Model: O Mechanical Linc Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: c.-..:...._ .._ Detector. Model: •J*% C.F'C'• ❑ Electronic Line Leak Detector. Model: O Tar.!; Ovcr`:: __ :' Scnsor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pa¢c 2). O Other (soecifv eouipmcnt type and mode! Disperser ID: l Z Dispenser ID: _ X Dispenser Containment Sensor(s). Model: AKI Dispenser Containment Scnsor(s). O Shcar Valve(s). ❑ Shear Valve(s). O Dispenser Containment Float(s) and Chain(s). O Dispenser Containment Float(s) and Chain(s). Dispenser 1D: t, Dispenser ID: - T-) 4 Dispenser Containmcnt Sensor(s). Model: "-4Q ZD -M-9— -,I Dispenser Containment Sensor(s). Alodel: 'J- O Shcar Valvc(s). ❑ Shear Valve(s). O Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Ct- kl:�, Dispenser ID: oRl Dispenser Containment Sensor(s). Model_'''_ M'?f0U Dispenser Containment Sensor(s). Model: O Shear Valve(s). ❑ Shear Valve(s). ODis enser Containment Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy ams torte. tncwae tntormauon for every ianr, amu uL.,F, - L- — .... J. C. Certification .I certify that the equipment identified in this document was inspected/serviced in accordarc^_ w-th the manufacturers' ;uidelines. Attached to this Certification is information (e.g. manufacr.. correct and a Plot Plan showing the layout of monitoring equipment. For :. attached a copy of the report; (check all that apply): ❑ System Set -t: Technician Name (print): rmn_y Fnnt-nna Signs Certification No.: (2Gir3"(nr\-t� ► License. No.: 184ut;Q Testing Company Name: Scott Co. of_Cali_forn a _ _ Phone No.:(�1 Site Address: c✓ionitoring System