COMPLIANCE INFO 1990 - 2008 - Laserfiche WebLink

Home Browse Search

MONITbWNG SYSTEM CERTIFI&TION • 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 This form mast be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control panel by the technician who perforins the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: C,o u mmg r M Aa&,t, Bldg.No.: Site Address: 17£59 WHST CHAAT&& Ly4a, City: Sne4erod Zip: 93'Zo6 Facility Contact Person: -5LW AIA L 0, PAZ Contact Phone No.: 5( 34.) ) 933- 1'78-<L— Make/Model 78`LMake/Model of Monitoring System: (/-,S A e co E Al C- Date of Testing/Servicing. 3 / /$/_1�3 B. Inventory of Equipment Tested/Certified Check the apgroeriate boxes to Indicate s irrc ui mem ins eted/serviced: Tank ID: t� I — ZO1J oo 6µ!.,d/-1 97 Tank ID: A Z- IZi 0&1 Z44Z,�I1 9/ • In-Tank-Gauging Probe. Model: • In-Tank Gauging Probe. Model:?4oZ6er�Zo ■ Annular Space or Vault Sensor. Model:PAoZSW144000 • Annular Space or Vault Sensor. Model:P,4oZ$F1ooW coo • Piping Sump/Trench Sensor(s). Model:"Z59y OOX I d • Piping Sump/Trench Sensor(s). Model:PAn 7,S'9"dpo/a O Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model:2,T• FX 1 -1/ 6 Mechanical Line Leak Detector. Model:Q T F Cl Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: • Tank Overfill/High-Level Sensor. Model:iiWP7-naee Pl't92 O Other ui men!type and model in Section E on Pae 2). O Others cify SSWE!amt type and model in Section E on Page 2). Tank ID: - Tank ID:_ O In-Tank Gauging Probe. Model: O In-Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: O Annular Space or Vault Sensor. Model: O Piping Sump/Trench Sensor(s). Model: O Piping Sump/Trench Sensor(s). Model: O Fill Sump Sensor(s). Model: O Fill Sump Sensor(s). Model: O Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model: O Tank Overfill/High-Level Sensor. Model: O Tank Overfill/High-Level Sensor. Model: O Other(specify equipment type and model in Section E on Pae 21. ❑ Others i ui men! a and model in Section E on Page 2).. Dispenser ID: * !f2 Dispenser ID: id 3 • Dispenser Containment Sensor(s). Model: PH05950000// • Dispenser Containment Sensor(s). Model: Pio O 5?S40&V ■ ShearValve(s). • Shear Valve(s). O Dispenser Containment Float(s) and Chain(s). O Di ser Containment Float(s)and Chain(s). Dispenser ID: A`511 6 Dispenser to: AlL 71 ■ Dispenser Containment Sensor(s). Model: PAO S9SV 0 47011 • Dispenser Containment Sensor(s). Model: Ph a59S0 OOd ■ Shear Valve(s). 4 Shear Valve(s). O Dispenser Containment Floats and Cham(s). O Dis nser Containment Float(s)and Chain (s), Dispenser ID: 9�lO Dispenser ID: TF ///a Cl Dispenser Containment Sensor(s). Model: !'14 0XlSO0b0// O Dispenser Containment Sensor(s). Model: Pi40 SV eGYLb!! O Shear Valve(s). O Shear Valve(s). UDispenser Containment Float(s) and Chain(s). O Dispenser Containment Floats 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 inspectedlserviced 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 a Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports,1 have also attached a copy of the repoo(check all rhant apply): ■System set-up MAI history r ort Technician Name(print): I-, g;56LL Signature: St a Met Krs Certification No.: X)C-;1K' Xlc- 2-46-T2 License.No.: gg�'"/2g�2- Testing Company Name: Phone No.:� 530 7S - 6/911 Site Address: /7ff lN• eA6;,e7"- Lt/A.7 Date of Testing/Servicing1.: 3 /�1� " R� ICC�((sl,�ij 'VI 0 Page I of 3 `� " \ OXVI Monitoring System Certification A P R o 2 2003 ENVIRuiw4iVIL1,11 HEALTH PERMi t/CERVICES