COMPLIANCE INFO_1988-2004 - Laserfiche WebLink

Home Browse Search

y 01/02/1995 93:27 2097545722 CALAVERAS ENV HEALTH MONITORING SYSTEM CERTIFICATION duthort!v Cited: Chap , 6-7, lieaath andSajery Code: Chapter 16. Division 3, Thee 23. Caltfontca Code of Regulat:o.ts This form must be used to document testing and servicing of monitoring equrpme t•t�s � re thank one monitoring system control panel is installed at tate facility, a to certification_. rn for each monsto_ri� ors I and by the technician who perforans thii work.. A copy Of this form trust be nstt�ID.�.,..tfSt P provided to the tank system: owner/OPer-aIor' The ownerloperator trust submit a copy of this form to the local Page - agency regulaTing UST sysiems within 30 days of test date. [astnictians are Printed on the back of this page_ A. GeneralInformatigr FxcilityNaxne: S -IM a ftmms; $}dg. No.: City- res,zip: G% '16 lr Facility Coutaet Person: ( Contact Phone No.: � Ual MaktNc dei of Monitoring System: flatc of Tesrag/SetYic ung: Z� B. Inventory of Equipment Teste-&Ce"Jlled to Tuba ID: PAG .✓ >C -1 ' io-Teak Gauging Probe Model:. is Armulw Space or vau4t Scniot- Modct' :- EM 10 Piping Sttrtrptrfrrnch Seusor(s). Model: ? �iL�lt "T Fill Stunp S ---(s)- Modes: C) Mccheicai Line Leak Detector. Leak Detector. Model: Model:i�- ja Erecuonic Line Madel- O Tank Orcrfill ! High-Lertl Scus0r. Model - C 1 nssp� Coatggnmenqscnrot(a}. Modet-4 �,k— Shen valve(:). Dispcn= Cortlaus icta Flow(s) and Chain(s). (] Ottfu t if tri [ stfd modet iq Section Eon Pa c . Tarek m: K 7- 6 in -Tank Gauging Probe. Medd: 4V a Atmular Space or Vault Sciasor. Model: `G - t .0 Pip ng Sampffrrnch Senaoc(s}. Model:. G O Fill Sump Sensor(')- Model: O kiccimrticA Line Leak Detector. Model: All Electronic Liffe Leak Dctectoc Modell:LZ�7_ 0 Tank Overfill / High -Level Sensor- Model- t Dispenser coett:iarrnrcnt Sensor(')- Modtt:.� �Gtir .� i$ Sl— valvp(e}. 13 Dupcam Contalituneart Fim4s) and Chain(s)- 0 Other (specify anpntent type and model in Section E on Page 2) Tank z / " 7 Qin- scale Gauging Probe. n Aiadei: 4 Amulaa Space or van8 Sensor- Model: it Piping Sutnptrrench Sensor(s). Model: !1 Fill SUMP Sarcor(s)- Model: 0 Mechanical Line Leak Detector. Line Leak Detector- Model: lktadel: alceerodic 0 Tank Ovcrfili / Higl4-Lcmel Sensor. Madel- I& DispwccrContatnmertt Sensor(s). Model_ Cts^ 5 a shear vafve(s). 0 Dispenser Containment Flox(s) and CbAm(s)- n ru k— r<a.,-if eau;mnent tvoc and model in Scctio:t E on Pave 2) - Tank m: 0 to -Tank Gaoging Probe- Model: Q Annular Space or vault Sensor- Model: Cl. Piping Sump(Treneh Sensor(s). model. 0 Fill Sump sensor(s). Model: 0 Mechanical Line Leak Detcaor- Model: (2 Electronic Line Leak Detector. Model: 0 Tank Overfill thigh -Level Sensor. Modcl a Dispenser Containment Sensor('), Model: 0 Shur Valve(s)- a Dispenser Conuimnent Flost(s) and Chain(s). 0 Daher tsaeeifv equipment type and model in Section E on Page�� C. Certif>feallon - [ cantly th it the equipment identified in this document was inspected/serviced in accordance with the Umnufacturtn' guidellues. Attached to this Certilicition is information (eZ. manufacturers' checkrsts) necessary to verify that this information is correct sod a Site Plan shouting the layout of monitoring equipment. For any equipment capable of fenerat[aa such reports, I have also attached a copy of tht (check all that apP r); O System set-trp rcpo c-� O Alarm history rt Technician bassets (print): L % e7tJ(ic. No•: ignanrre: . Testing Company Name Phone No �) oarthr� t -d Zis89-19fr (602) umo.ag 81.t,ae0 eS6:60 60 Be Rew