COMPLIANCE INFO_1999-2009 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Susie of Cavornia Aruhority Cited: Chapter 6:7. Health and Safety Code: Chapter 16, Division 3, Title 23, California Code of Regulariow This form must be used to document testing and servicing of monitoring equipment. A s=m= celcation or report must be prepared for each monitoring system control panel by the technician who perforans the work. A copy of this fort must be provided to the tank system owner/operator. The ownedoperator must submit a copy of this form to the local agency regulating UST systems within 30 days oftest date. FLAME LIQUOR- MINI MART A. General Information 1301 W. KETTLEMAN LANE Facility Mame: LODI, CA 95242 _ Bldg. No.: Site Address: --- ----� Zip: Facility Contact Person: Contact Phone No.: f ) Make/Model of Monitoring System: -I I --A rr -a (L Date of Testin Servi ' i �d 5/ll, !`� - B. Inventory of Equipment Tested/Certified EUrt-Tank Gauging Probe. Model: 1-1 Annular Space or Vault Sensor. Model: Lt `..Piping Sump / Trench SeAsor(s). Model: > a 0 Fill Sump Scnsor(s). Model: (K Mechanical Line Leak Detector. Model: � 4 __....� 0ElectronicUneLeek Detector. Model: 0 Tank Oveffll ( f£tgh-Level Sensor. Model: 0 Other tsnacifv eouinmerat rvne: anti mrviai in .RP.rlinn F n.,a P.— 91 Tank 111): Y-) ,r" c ZK�n-Tank Gauging Probe. &kAnnular Space or Vault Sensor. 9 Piping Sump / nench Sensor(s). El i=zu Sump Sensor($). ZMechanieal Lane Lealc Detector. U Bietdzonic line Leah Detector. 11 Tank Overfill / High -Level Sensor. Model. 8r 73 Model: 4 2_:� Model: r& `2 Modell- odel:Model: 17 F911 Smnp Sensor(s). P -Mechanical Line Irak Detector. Model: - a— model: Modol: Model: Q Tank Ovetfill / High -Level Sensor. Model: Tank iD: 5 ln-Tank Gauging Probe Q.Annular Spare or Vault Sensor. C.4 tD, odes. -7 6 a Model: 7e - I Taa m: ❑ la -Tank Gauging Probe. Model: ❑. Annular Space or Vault Sensor. Model: _Piping Sump / Trench Sensorls). Model: , D Piping Sump / Trench Sensor(s). Model: 17 F911 Smnp Sensor(s). P -Mechanical Line Irak Detector. Model: Model:...?. D Fill l sump Sensor(s), Model: D Mechanical bine Leak Detector. Model: Q Elccuottic lane Leak Detector. Modol: Q Blectmnic Line Leak Detector. Model: Q Tank Ovetfill / High -Level Sensor. Model: 13 Tank Overfill ./ ugh -Level Sensor. Model- Q Other t and model in Section E on 2). Q other a r» and epode! in Section E on LaLe 2). Dispenser ®: DispenserID: , QDispenser Containment Sensor(s). Model <] Dispenser Containment Sensor(s). Model: Shear Valve(s). W Shear Valve(s). Die ser containment F7oat(s and Chain(s). 10 Di sea Containment Float(s) and Chains L_ Dispenser- ID: Dispenser ID: Q Dispenser Containment Sensor(s)_ Model: Q Dispenser Containment Sensor(s). Model: El shear valve(s). � Shear V.)V a(s). D; ser Containment Fl s) and Chain(s). Containment Float(s) and Chain(s). Dispenser ID: I TH ID. Q Dispenses Contaitunent Sensor(s). Model: ❑ Disp-, — Containment Sensor(s), Model: U Shear Valve(s). O Shear Vaive(s). QDisDenw Contaiatment Foat(s) and Chain & Q D` ser Cantaimueat Haat(s) and Clrain(s). *If the facility contains more tanks or dispensers, copy this forret. Include information for every tank and dispenser at the facility, C. Certification -I certify that the equipment identified in this document xas inspected/serviced In accordance with the manufacturers, guidelines. Attached to this Certincadon Is information (". m mufgciarcrs- cheddIM) neogmary to verify that this i[Se utation is correct and a Plot Pian showing the layout of monitoring egapmenL For anyequipment fible of generating such reports, I have also attached a copy of the report; (check ani fhb ly): d4ystem set-up Ala t Itt r report Technician Mame (print). i. ( (C2 11 Z. Signature: Certification No.: (. 7 2) 'c' License. No.: `1) ,: `-" Testing Company Name: Z 77-6 Phone Site Address: 1301 Vr -telC&IDaae of`Tesiirrg/Servicing: ' rag 1 of 3 03!01 Monitoring System Certification