COMPLIANCE INFO 2003 - 2006 - Laserfiche WebLink

Home Browse Search

moNrrO&G SYSTEM CERTIFICATE 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 must 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 performs the work. A copy of ties form must be provided to the tank system ownedopetator. 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 P6 (J 1(7/ Facility Name: Bldg.No.: Site Address: 9 6 49la 1 o rz-ltd/z7°`1 lew City: 1 y C l� Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System TL 5 3 S Date of Testing/Servicing: B. Inventory of Equipment Teste&Certified 'po�Ye/ yO 6 Check thea roriate boxes to indicate specific equipinent serviced: Tank ID: V / 11 / Tank lir i ❑ In-Tank Gauging Probe. Model: A1✓ ' jo,In-Tank Gauging Probc, Modd: Ni A 4T J El Annular Space or Vault Sensor. Model: UAnnular Space or Vault Sensor. Model: Cl Piping Sump/Trench Sensor(s). Model: ;2 a 4 Piping Sump/Trench Sensor(s). Model: 61- ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: f-Mechanical Line Leak Detector. Model: J x--.1 11-Mechanical line Leak Detector. Model: L D a u a`' C3el-Electronic Line Leak Detector. Mod ❑ Electronic Linc Leak Detector. Model: Tank Overfill/ Model:OPu/6 i,;76'`-t l o A-Tank Overfill/OV9g 1 Sensor. Model: d dew 61,3o ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Tank ID•A 3 F7 Tank ID• •Q,In-Tank Gauging Probe. Model- ✓A A 41A i ( ❑ In-Tank Gauging Probe, Model: A Annular Space or Vault Sensor. Model: <70 7 ❑ Annular Space or Vault Sensor. Model: 6-Piping Sump/Trench Scnsor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: C4Fill Sump Sensor(s). Model: ❑ Fill Sump Scnsor(s). Model: Mechanical Linc Leak Detector. Model:-zj2 �7 ❑ Mechanical Ghe Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Linc Leak Detector. Model: Tank Overfill/Hig4-L2mGL.'jcnsor. Model&"ic,d n // y p ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(spccify cqui rnent pMc and model in Section E on Page 2). ❑ Other(spwify equipn= t=and model in Section E on Pa a 2). Dispenser ID: / 'L-' Dispenser ID: 3 ❑ Dispenser Containmc t Sensor(s). Model: Cl Dispenser Containment Sensor(s). Model: 09LSh=Valvc(s). 2�,Shear Valve(s). 2LDispcnscr Containment Floats)and Chain(s). EMispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valvc(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valvc(s). ❑ Shear Valvc(s). ❑Dispenser Containment Float(5)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 fac ' 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 a Plot Plan showing the layout of monitoring equipment. For any equipment capable of e1`ating such reports,I have also attached a copy of the repo�rt„(�check all that apply): }rstem set-up 0?9ti; -port i Technician Name(print): i, C- y 2 64" A tJ Signature: < CeNification No.: License.License.No.: Testing Company Name:Z"r%nS7!IICkN P Phone No.:(�I) F) F3."d7 - -10 A 0 Site Address 1 S 2<, CA 9(:50 Date of Testing/Servicing:G/-(�—��Z-- 1'a c 1 t3 uiul Mmlitm in_ >trnt Ccrul-Icatiun