|
MONTT(!),tUN SYST.N111 CIEcTiFICA"I'iUN
<br /> l,or Use BY All,lurisdictiors With/n th?5t,71^GfC,71if;Y�rda
<br /> Authority Cited: Chapter 6.7, Health and SgJety Code; Chapter•16,Division 3, Title 23, California Code of'Regulations
<br /> This form must be used to docuni;-ni tstiag diad servicing of monitoring equipment. A separate certific u
<br /> each oQLCgport must be preyarad
<br /> for monitorinYsystem� b)•+La .e la :c n srh�ra,a., rs tt;a ,.., a �.,,.� :,.t:: �' t3 il:_ task
<br /> system owner/operator. The owner/operator ]lust auumi( a ceps of i1114 lout, tv u:e roehl ageiiry iegulat;ag UST systems within 30
<br /> days of test dLt
<br /> A. Genem!
<br /> Facility Name: L•l4&otCLO 19 --- - - - - — Bldg. ........ -
<br /> Site Audiess^ �i t � J� �.►\V'-' _ _._ . _ l tYr;�,`!l�ti�y.t' Zi,fi C • c?
<br /> - —_ (—nC—t —.? r�.�,; �;_ jFaciii
<br /> Facility Person ,..._..,ca..
<br /> _.�,•4_
<br /> Make/Madel of Monitoring System:;'!! :`_"_C, '+,._- 2�; ��----- ( -"—_ r a t d 3c' ci 1g• =
<br /> B. Inventory of Equipment Tested/Cert lFa,,i
<br /> Check the sporo rlate xe to Indieste cil7c Muln�nt tn� �!�l/ee:vtcad; _
<br /> Tank IU:
<br /> 4 in=Tank Gauging Probe. Model• "��/�l' _ I in-Tank u_,if,r,g,Prohc. Model:' �';:-3 `•1Cn
<br /> it Annular Spice or Vault Sensm M^del:; � �u;r ui::r t;pr,a or Vada Sensor. l�todei. 'INr S ''6`.'�O'r "
<br /> Piping Sump/Trench Sensor(s). Model:`�'i .—_'V� `t•Fi..i,t; ur tp d6 —01 -
<br /> Fill Sump Sensor(s). Model:,700 '_3 �' i''.Sump`,e, cr s). Ivlouc':f
<br /> ❑ Mechanical Line Leak DetrctorMod.?! _• _ ___ L? I�IC,:i:1!1U;ei!jr,!1.(,;;k 0a t'l!ci^r, ;�loJWl:
<br /> 1$ Electronic Line Leak Detector, Mode!' _ x?� ._ —_ _- d�'91 171rwftonir t inP t eek netec:or, Mpdel:-1f
<br /> 11 Tank Overfill/High-Level Sensor. Model: �._ J rank Ovc:fia i Htgn-La:ei Sensor. �1
<br /> Q Other(s erl�fy a t!1 mcut type and ni_odel :r Section'r,x 13 2 i 011r- %-,41-e me nic-R!-'n StcOw.,2,3n Frijz
<br /> Tank(D: -
<br /> ❑ in-Tank Gauging Probe. Model c�•"." �., +..fit ❑ ::.-:'a�k i;aa�+ng i"rc,'v�. .moaei: --------
<br /> O Annular SpACs or Vault S"ms-u. NQoL'el: 1? ! �._ ;��4^'_ L� I`,NW:.t a-okV sir V!kL;t SLUM :. iLd11: _
<br /> ❑ Piping Sump/Trench Sensor(s), Model: ❑ Piping Sumo/'Trench Sensor(s). Model: _
<br /> ❑ Fill Sump Sensor(s). Model: • ___-i ❑ Fiil 4r!r,i'.ufu:,!1 !11vue,: _ ______
<br /> ❑ Mechanical Line Leak Detec-tnr, N4,!ie' .3 "c ..r!.. i e -r.`:
<br /> Electronic Lille Leak Detector. Model: ° _ I :J Electronic Linc Leak Detecto(. Model
<br /> ❑ Tank Overfill/High-Level Sensor. Model: — C !i=tl', Cee:- ,'1/:'ibh Leve: eraar. l;;�del:
<br /> ❑ Other(specif
<br /> y equipment t c and model in Section i or P lyP 7 _ !) r1thrr frC^,ir•bn'•i^� -jt t �a�tr+r�tode!tr.S!v_tion F.oti Pae 2 .
<br /> i,_ ._._.... ..-....t.. ..tC_-
<br /> Ispenser ID:.(//�„-_�_--..._ _ Dispensor 4):
<br /> Dispenser Cotfainment Sensor(s). Mode WSA,q- l ZOO' 6VDispenser Containment Sensor(s).
<br /> ShearValve(s).
<br /> O Dispenser Containment Floats and Chain (s). ❑ Dis ensu. Conta,mnen:F lost s and07
<br /> rtatt(il_,. Y�,_.�.'r_,...•�"
<br /> Dispenser CD:_ _ E Dispenser 11i:_�Y.-.-
<br /> 6Dis„-nser C^ ,a,ir :'f ir:^.9(:{.;s
<br /> 1 r'� Z! t�•�[t .,•oor e A V. �r Z.
<br /> -
<br /> � ---
<br /> ❑ Sher.!Vstve(s). 0 Li ,;.lest k'elveks).
<br /> ❑ Disnenrer Coria;r:r:en,F'c�t�s�:ad G?.air ;s). ' +zt Dia nicer C:ontalnment Fioa 'tt and Chain (s).
<br /> 3penseriD: __-- -- DlspenserlD:---_-_--- -- -_-_._• .._ _. --
<br /> ❑ Dispenser Containment Sensor(s). Model O Dispenser Containment Sensor(s). Model: _
<br /> ❑ Shear Valve(s). U Sheat Valve(s).
<br /> ❑Dis enser Containment Floats 1.1 Uiy ens.:Containment iiriba s and Chains .
<br /> *If the facility contains more tanks or dispensers,copy this form. Include inforra+ion for every tank and dispenser at the facility.
<br /> C. Certiflcaflu l -i certify that the equipment ide,flJ14!:i In thta document was inspected serviced in accordance with the manufacturers'
<br /> guidelines. Attached to this Certificatit n is 'n i,• rn Iii► i (e.,v. 'fir I',"$: ttr,r t' cb,ckii 11.41 necessary to verify that this Information Is
<br /> correct and a Plot Plan showing the layout of munitrrring equipment. ror any equipment capable of gentritting such reports,i have also
<br /> attached a copy of the r ort;(check gMthat appl): J System set-up 0 larm history report
<br /> "Technician Name(print): J Uti, •� Signature:
<br /> Certification No.. _ _ License. No.:
<br /> Testing Company Na Phone Phone No.:(_ 5� � b
<br /> Site Address: �_�_ .—� r✓ . Date of Testing/Servicing /tat r�
<br /> UN-036-1/4 Page 1 of 3 Rev.06/04/01
<br /> www.unidocs.oru
<br />
|