COMPLIANCE INFO_1987 - 2005 - Laserfiche WebLink

Home Browse Search

MOi ,_ _ ORING SYSTEM CERTU.,ATION For Use By All Jurisdictions Within the State of California Authorin,Cited. Chapter 6.7, Health and Safen>Code.Chapterd6, 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 nmoared for each monitoring system control oanel by the technician who performs the work_ A copy of this form must be pro- to thg`zank system owner/operator. The owner/operator trust submit a copy of this form to the local agency regulating UST sys rests wahin 30 days of test date. C �= A. General Information Y Facility Name: T V (C 91-� F Bldg.No.:`�_ Site Address: -3 il ,��Y City: 5 TaeK 7-n eo e-A, Zip: s Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: CIA-1 k t_ L e a I f-"-1 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified _ Check:the appMriate boles to indicate s dtic went serviced: Tank ID: I Tank ID: ❑ In.Tank Gauging Probe. Model• ❑ In-Tank Gauging Probe. Model: C"Annuiar Space or Vault Sensor. Model: L W F- ❑ Annular Space or Vault Sensor. Model: R'Nping Sump/Trench Sensor(s). Model G S A/lS C ❑ Piping Sump ITrench Sensor(s). Model: Fill Sump Sensor(s). Model ❑Fill Sump Sensor(&). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector_ Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill 1 High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. .Model: C3Other(s ecif,equi merit=and model in Section E on Pm 2). ❑ Other(specify equiEMnt type and model in Section E on Page 2). Tank ID: Tank ID: ❑ in-Tank Gauging Probe. 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/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). ModeL• L3 Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model ❑ Tank Overfill/Higb-Level Sensor. Model: ❑ Other(specify vment and model in Section E on Pae 2). ❑ Otho( ecifv t and model in Section E on P e 2). Dispenser ID: " Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Disp5nser Containment Float(s)and Chain(s). t3 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). ❑ Dis user Containment Float(s)and Chain(s)- ❑ Drs Containment Float(s)and Chain(s). Dispenser ID; Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear valve(&). ❑ Shear Valve(s). ❑Dispenser Containment Floats)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). t '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 inspectedlservieed in aeewdanee with the manufaekurers' 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,I have also attached a copy of the report;(check all that apply): Q System set-up ❑Al historypre Technician Name(print): 4,,j t jJ C A lL,t3«htJ Signature: Certification No.: License.No.: Testing Company Name: -4.•-¢,K/�tt;a1 �/Z �cSl�s �,g -(-`�s'Ti�PhoneNo.:� `'D � �L-�— �'f`i' Site Address: 3 t;'6.S_ f'L',^1�'Y 5 78 C-k?a I.1 / C 4, Date of Testing'Servicing: Page 1 of 3 03/01 Monitoring System Certification a