COMPLIANCE INFO 2002 - 2006 - Laserfiche WebLink

Home Browse Search

MONIT*ING SYSTEM CERTIFIATION �Iutllority Cited; Chapter 6.7. Health at� SafetyrCode; Chapter )6.11Dile v'sion le 3 Title 23,rCalrrorttia Code oj Regulutions This fOrrn must be used to document testing and servicing of mortiloring equipment. Ase arate ccrtifica 'on re ort be u t be re ar d for each m nitorin S Stern control a ei by clic technician who performs the work. A co py of system ownerloperator. The owner/operator must submit a copy of this forni to the Local ag ncly reis gulatingUST systems within ded ctank days of test date, 30 A. General Information Facility Name: to Site Address: `=l O lvlC.►- ii�c r,,4f Bldg. No.: City: fa�� Zip: c Facility Con(act person: e Tv Contact Phone No.: (�?� MakeJModcl of Monitorigg Syste,n: c CG t �� e 'S Datc of Testing/Servicing: B. Inventory of EquiPment Tested/Certified Check the ""-o nate boxes to indicates cclfltt a u! mcnt Ins ccted?serviced: 1;� In-Tank Gauging Probe, Tank ID: 3 S Model: Z• , 7 L' t1/ Q In-Tank Gauging Probe. [�4,nnular Space or Vault Sensor, Model: �+ .: -.�•, Model; 23- Piping Sump / Trench Sensor(s). Model: J q ❑Annular Space or Vault Sensor. Model: PLFiil Sum Sensors . 4t C c�> ❑ Piping Sump/ Trench Sensor(s), Model: p O Modcl: �� /l _ I❑ Fill Sump Scnsor(s). : CI Mechanical Line Leak Detector. Model: ❑ ModelMechanical Line Leak Detector. Mode: �4 Electronic kine Leak Detector. Modcl: ` K Tank OvCrfil! / High-bevel Sensor. Model: L� i 4 Q Electronic Linc Leak Detector. Model: ❑ Other s ecif a ui ment t e and model in Section F on Pag2. ❑ ^.I- - ,sD Tank 1 ecif /e equipment nt t Se and model in Section E on Page 2 Tank ID: (.',C` r� F�r� CF VT In-Tank Gauging Probe, Model Tank 2n `id -I/! ❑ In Tank Gaugittg Probe. Mcdc1: '3 Annular Space or Vault Sensor. ModcI: 7 `rel �," _ ZI Piping Sump/ Trench Scnsor s . Model' ?rZC ID Annular Space or Vault Sensor. Model: () 3(eC �- gl' ❑ Piping Sump/ Trcnch Sensor(s). Model: Fill Sump Model: >�� 13 Fill Sump 5cnsor(s), Madel: ❑ Mechanicall Line Linc Lcak bcicctor. Model: ❑ Mechanical Line Leak Detector. Model, Electronic Linc Leak Dctector. Modci: $ Tank Over / High-Level Scnsor. Model: �' -7 -7 �� ❑ Electronic Linc Leak Dctector. Model: Other s ecif c ui mcnt t e and mode! in Sec;; on E on p 2) � ❑ Other (s c0 Tank c f 11 /C uihmcn-Le�t [ ce and model in Secti9P1,L Page )ispenser jp; � d � 4 Dispenser Containment Scnsor(s). Model s�C-2tp Dispenser ID: -- Shear Wve(s). x 1'Dispenser Containment Sensor(s). Model: Dis cnser Containment Floats and Chains . RF Shcar Valve(s). ❑Dis cnser Containment Floats and Chain()ispenser ID: ZDispenser Containment Sensor(s). Madel: G. ,, Dispenser ID: I Shcar Valve(s). - ' n`� _ i; Dispenser Containment Sensor(s). Model: '75' I Dis cnser Containrncnt Floats and Chains . 12-Shear Valvc(s). ispenser ID: -15 LlDis cnser Containment Floats and Chains • C Dispenser Containment Sensor(s). Model: cl ^ r _ �`- Dispenser ID: �� f Shear Valvc(s). ❑Dispenser Containment Sensor(s). Model: 'Dis cnser Containment F}oats and Chains . Q Shear Valvc(s). f the facilityp p ❑Dis Dispenser Containment Float s and Chain 5 . contains more [auks or dis enacts co y this form. Include information for every tank and dispenser at the facility. • Certification -I certifv that the equipment identified In this document was in spectedJservlced in accordance with the manufaetnrers' guidelines. Attached to this Certification is information (e.g. manufacturers' Check}fists) necessary to verify that this information Is correct and a Plot Plan showa showing the layout of monitoring equipment. For any equipment capable a generating such reports, I have also attached a copy of the report; (check all rhat appfj)- Cl System set-up O Alarm hiable o g rt :chnician Narne (print): , / 7 Signature: rtiftcation No.: C' e, — License. No.:, sting Company Na�mc: Fi el Address` Yz i 7 , Phone el* _ i l! l C,r j �/ Date of Testing/Servicing: g• ,_ icin �._ Pa nitoring Systern Certification ve I of3 03/01