COMPLIANCE INFO_1987 - 2005 - Laserfiche WebLink

Home Browse Search

. r --MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Author•in•Cited: Char:c r u.7. Health and Strfen•Code; Chapter 16, Division 3, Title 23. California Code of Reg Mations This form must be used to document testing and sen-icing 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 tangy- SySt-m owner or_-r:;;,:%r. Tl„ owiler'operator must submit a copy of this form to rhe lnc ' aar!ncy rno„in,;.,a Uc within 30 days of test date. ` A. General Information Facility Name: 5 T 54�7Au i e Q�rs _ Bldg. No.: Site Address: 3 s o 5 ,v,4 v y oar Cir< �57'z3< e1x_-7Zfl) Zip: Facility Contact Person: Contact Phone No.: (� Make, ode' of Monitoring S}stem: 2M N7' pIDate of Testing%Servicing: C(/ a? B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: /— LL;4,-rz!6r &J4' Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: OrAnnular Space or Vault Sensor. Model: vytee ❑ Annular Space or Vault Sensor. Model: I 2 Piping Sump/Trench Senson,$). Model: ae� ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: j ❑ Other(s ecif e ui ment tyt:�e and model in Section E on Page 2). ❑ Other(soecifv eouioment type a-'-nodel in Sec, E on Page 2). Tank ID: Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: II ❑ Piping Sump/Trench Sensor(.$). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: jI ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 1 ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sense-. Model: ❑ Other(specify equipment t%pe and model in Section E on Page 2). ❑ Other(soecify equipment tv e ar..� ode'in Section E on Page 2 . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Rlod-1: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). II it ❑ Dis enser Containment Floau s)and Chain(s). ❑ Dispenser Containment Float(s)a-d Chain(s). jl Dispenser ID: Dispenser ID: u ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). II i Flvaz,s,u ..,::a,:,is,. p r ✓Siic:nsc:CGtttaut::ri:t i waiiai _ _ Cuauu�l. [—Dispenser ID: Dispenser ID: iI ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). I C1 Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s) Chain(s). *If the facility contains more tan's or dispensers,copy this form. Include information for every tank and dispense-at the facility. C. Certification - I certify that the equipment identified in this document nvas inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessan• 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): ❑ System set-up ❑❑ Mar hi ori report Technician Name(print): .qr..✓,0 C., /L1/L✓�gA#J Signature:�&x Certification No.: License. No.: 90Y5?'2c7 Testing Company Name: �eZ1cJ ,Qi�C1S��J �`/�N.1C ' / Phone No.:� v* Site Address: _ �7�iz ,qv U'z, STac 1�7�� t �i9 � Date of Tesr:n?'Servicing: Page I of 3 03/01 Alonitoring System Certification D. Results of Testing/Servicing