COMPLIANCE INFO 2002 - 2005 - Laserfiche WebLink

Home Browse Search

MOORING SYSTEM CERTWI CATION For Use By All Jurisdictions Within the State of California Authority Cited.: Chapter 6.7., Health and Safelly 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 senarate 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 Name: AUd 1 Ci Bldg.No.: Site Address: 132 c111' MP-11 M=A/ City: _Lad i. Zip: _ Facility Contact Person: c-)-C � ��[� � /{/ Contact Phone No.: � "� �Q G Make/Model of MonitoringSystem- l CICOCI'� �aa� 7-L S - So t—) 1 Y r � Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the appro2Hate boxed to indicates e i ment serviced: Tan}t ID: CA rl < Tank ID. 2 L,(PI L �'°Tank Gauging Probe. Madel: 0�— �O 41/ Tank Gauging Probe. Model: f �7O d�jtmular Space or Vault Sensor. Model: c/ a/ Annular Space or Vault Sensor. Model: 7`�'`/7�4— (12 6 tping Sump/Trench Seasor(s). Model: 7 'ci ©-1.2 ®'piping Sump/Trench Sensor(s). Model:gan c('ZJU•2a5f ❑ Zill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: L(a _I&C' Or 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(s ec• ui went type and model in Section E on P2Ze 2). ❑ Other(speca equigment(spec' and model in Section E on PaLe 2). T ID: l'1 t S>?L Tank ID: O t��Piping Tank Gauging Probe. Model: S'76 f — 7?O ❑ Tank Gauging Probe. Model: nular Space or Vault Sensor. Model 2 r7 c/��O -'4 20 L�t?�/ °pular Space or Vault Sensor. -Model: 7�I`� 6 `( Z6 Sump/Trench Sensor(s). Model: Q)F e1?JZ) -1 4)r U Piping Sump/Trench Sensor(s). Model: e)7"1 `( ❑dill Sump Sensor(s). Model: Ll Fin Sump Sensor(s). Model: ®'Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ lectronic Line Leak Detector. Model /U LJ Tank Overfill/High-Level Sensor. Model: [!f Tank Overfill/High-Level Sensor. \Mode o�f yl %1 ❑ Other(s eci w" mens type and model in Section E on Page 2). ❑ Other(speca equipment(spec =and model in Section E on P e 2). Diss ID: Lk 4L t Dispenser ID: {d dispenser Containment Sensor(s). Model: 07�?9 30-ZM- ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Ll Dis user Containment Float(s)and Chain(s). B Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ 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: Dispenser ID; ❑ Dispenser Containment Sensor(s)_ Model: ❑ Dispenser Containment Sensor(s). Model: 1❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis nser 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 eertify that the equipment identified in this document was inspeeted/servieed in acew dance with the manufacturers' guidelines. Attached to this Certification is information (e.g. ufacturers' ch ts) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring eq ment. For any equi nt capable of generating such reports,I have also attached a copy of the reaQyct;(check that apply): System set-up Al his Fe ort Technician Name(print): C Signature: Certification No.: S��1s..ZLLc/ License.No.: Testing Company Name: - 7Avi o ey �! 't l� 7�S %vt_ti Phone No.:( a0 ) 670 -7 T Site Address: 0 f CJ X 13 0 S-i So,<; cfp+ �j S �1� �G�� Date of Tesdng/Servicing; /_/ Page 1 of 3 03101 Monitoring System Certification