COMPLIANCE INFO_2004 - 2007 - Laserfiche WebLink

Home Browse Search

19255517888 Main Fax GETTLER RYAN INC 09 19:00 a in 01-12-2007 2111 MONITORING SYSTEM CER ION 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 This form must be used to document testing and servicing of monitoring equipment. A_separate certification or report must be prepared for each monitoring system control pastel by the technician who perforins the work. A copy of this form must be provided to the tank system owner/operator. The owner!operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: ..__. f C0 Bldg.No.:��0 Site Address: LQtJ:SC Jam- City:_l cr'ArDp Zip: Facility Contact Person: _ ________� Contact Phone No.: 2c 05 )- 9e.-� 9 1 v Make/Model of Monitoring System: _T� - 3r� Date of Testing/Servicing: A.21—)D1 o� B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: e TP Tank ID: ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Spacc or Vault Sensor. Model: ft Piping Sump/Trench Sensor(s). Model: q q,3PO-3.2 3 ❑ 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.I Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model_ ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2)_ Q Othcr(specify equipment type and model in Section E on Page 2). Tank ID- Tank 1D: ❑ 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 Scusor(s). Model: T Q Piping Sump/Trench Sensor(s). Model: Q 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: U Other(s ecity equipment type and model in Section E on Page 2). ❑ Other(specify equipment type and model in Section E on Page 2). Dispenser ID: _._ Dispenser ID: Q Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). O Dispenser Containment Float(s)and Chain(s). Dispenser ID: __ Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: _ ❑ Dispenser Containment Sensor(s). Model-_.______ ❑ Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). U Dispenser Containment Float(s)and Chain(s). Dispenser ID: __� Dispenser ID: O Dispenser Containment Sensor(s). Model: U Dispenser Containment Seusor(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 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 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 Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attachA a copy of the report;("check all that apply): Q Syste et-up 0 Alarm history report Technician Name(print): _Lc,nd (?CO3Jn Signature: Certification No.: 13 f r ___ License.No.: Testing Company Name: 6,e'ftler-dV____-jey' �}n _�nr C. T Photte No.;�_2rj'� sS/ `Y 77 7 Site Address: Apr A___1-___.10.11, Ac La-hrOp Date of Testing/Servicing: Page 1 of 3 03/01