COMPLIANCE INFO 2010 - 2018 - Laserfiche WebLink

Home Browse Search

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 t This form must be used to document testing and servicing of monitoring equipment. I€r+tere +a �e;�h rucian who performs the work tlte-tetiity-e-A Separate certification o report must a vresrp*P� for a sh ^+�nitnrinQ�yStem contT4Lp ne by A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit e'ctrpy of this form to thelocal agency ` regulating UST systems within 30 days of test date. MAR 2 12016 A. General Information ENVIENTAL Facility Name: Ar_� N Site Address: G n ► City' Zlp. Facility Contact Person: Contact Phone No.: ) Make/Model of Monitoring System: 74t) �S` Date of Testing/Servicing: ` R. Inventory of Equipment Tested/Certified Check the 6propriste boxes to tnditate a cifle equipment Inspected/serviced+: Tank ID: Tank ID: ❑in-Tank G}R&g Probe. Model: ❑In-Tank gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor, Model: Piping Sump/Trench Sensor(s), Mod ct: Piping Sump/Trench Scnsor(s). Model: `• Z3 0 Fill Sump Sensor(s). Model: '~ Pill Sump Sansor(s). Model: 7- 19ahanieal Line Leak Detector, Model: Mechanical Line Leak Detector. Model: FV KO jgtcctronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: fit Tank Overfill/High-Level Sensor, Model: Tank Overfill/High-Lavcl Sensor. Model: ❑Other(specify equipment type and model in Sectio Page 2). ❑Other(specify equipment type and model in Sectio on Page 2). Tank ID: Tank lD; ❑in-Tank Gauging Prolx. Model: ❑In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: _ ❑Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: - ❑Piping Sump I Trench Scnsor(s). Modol: Fill Sump Sensor($). Modch - ❑Fill Sump Sensor(s). Model: AMechanical Line Leak Detector. Model: ❑Mechanical Line Leak D)ctector, Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Usk Detector. Model: ,I Tank Overfill/High-Level Sensor. Model: MQ0 Tank Ovcrrill/High-Level Sensor. Model: ❑Other(specify equipment typo and model in ection n Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser 1D: Dispenser ID: j)Dispenser Containment Sensor(s). Model: X Disperser Containment Sensor(s). Model: -.. ❑Shear Valvo(s). ❑Shear Valve(s). ❑Dispenser Containment Floar(s)and Chaln(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 1 — L Dispenser ID: 9 —i-b Dispenser Containment Sensor(s). Model: y IN Dispenser Containment Sensor(s). Model: '--' ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(,). Dispenser ID: It Dispenser ID: �+ Dispenser Containment Scnscr(s). Model: ,�"j [WDispenscr Containment 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 teaks or dispensers,copy this form. Include information for every tank and dispenser at the f4cility. 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 Site-Plot Plan showing the layout of monitoring 1pment. For any eq)i went capable of generatln such repo,I have { also attached a copy of the report;(check all that apply): f System set-up Alarm history repo tai CAA Tb Technician Name{print): Tony Fontana Signature: Certification No.: V.R.A23688 ICC 5289227-UT License,No,: A-646 Testing Company Name: U.S.T.COnWilance Testlnn Inc. Phone No.:(209) 69544489 Testing Company Address: P.O. Box 580 Ceres, CA 95307 _ Date of Testing/Servicing--75—JL, iJ1V-036-f/6 www.unrdoes.ore 0T. T 'd S'SH'`99h 01 96ST-T2S-602 JNI sS ii-dwoo-isn:w0cid Tb:zO 9TO2-6T-6UW