COMPLIANCE INFO 2006 - 2012 - Laserfiche WebLink

Home Browse Search

Appendix VI MONITORING SYSTEM CERTIFICATION 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 this form must be provided to the tank system owner/operator. 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 Q /^ e r Loy), r Bldg. No.: Names• Site D ! � rl,()'v City: tj .Caf, zip: ArfrlrP..Rw Facility Contact c Facility L� Contact Phone No.: � 01 G0, PP �J o, Make/Model of Monitoring System: 1% T ,L S C7 Date of Testing/Servicing: 1, B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicatespecific a ui ment ins ectedlserviced: Tank ID: i/� �-- Tank ID: 4 In -Tank Gauging Probe. Model: n7 Q / ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: �% - ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: oZ 0 g ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ 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: Z) t -f P_ Tank ID: In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: S;ah t Ol n' ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Modei: 5L iV ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: �j Mechanical Line Leak Detector. Model: 5 Tri, Al ❑ 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 (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: 1 k ;. Dispenser ID: 6)1_j 4 ❑ Dispenser Containment Sensor(s). Model: Q `[ti ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s), ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: a V'!% b( Dispenser ID: 7' - (s' ❑ Dispenser Containment Sensor(s). Model: F ❑ Dispenser Containment Sensor(s). Model: .57, ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment ❑ Dispenser Containment Sensor(s). Model: Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) 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 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 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 report; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name (print): Lyle D. Nimmo Signature: 0!�llG<G Certification No.: 0605 License No: 1143 Testing Company Name: AFFORDA-TEST Phone No, 209 744-0113 Testing Company Address: 416 0- STREET GALT, CA 95632 Date of Testing/Servicing: Monitoring System Certification Page 1 of 4