COMPLIANCE INFO_1993-2002 - Laserfiche WebLink

Home Browse Search

Jun15-2002 03:16pm From-ARCO PRODU +T14-670-3095 T-919 P-002/006 F-953 MONITORING SYSTEM CERTWICATION For Use By All Jurisdictions Within rhe Stat, of California Aurhority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, 71tle 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A seRarate certification or report must he nre28red fpr each monitoring sysiem control 2nnel by the technician who performs the wort:. A copy of this form must be provided in the tank system owner/operator. The owner/operator must submit a copy of this form to .hw local agency regulating UST systems within 30 days of test date. A. General Information Facility Name. -_ Bldg.No.: Site Address: City: t Y�C1 C�/ Zip: Facility Contact Person; Contact Phonts No.: Make/Model of Monitoring System: ko Date of Testing/Scrvicing: I B. Inventory of Equiprtaent Tested/Certified Cheek thea ro Tints boxes to ladieate qNCiflC a ni Ment inn ected/servieed: Tank ID: 13 In-Tank Gauging Probe. Model: ❑ in-Tank Om sins Probe. Model: A2 Annular Space or Vault Sensor. Model: Annular Spi-ce or Vault Sensor, Model: A(Piping Sump/Trench Scn5or(s). Model: 19 Piping Sump/Trench Scnsot(5). Model:L- WFill Sump Sensor(s). Model: _. +I-Fill Sump Sonsor(s). Model: _ 40 Mechanical Line Leak Detector. Model: -- -------— ❑ Mechanical Lane Leak Detector. Model- 5L Electronic Line Leak Detector. Model:RgD GPT U Electronic Line Leak Detector. Model: - ❑ Tank Overfill I High-Level Sensor. Model: ❑ Tank Overfiti I Hight-Leve)Sensor. Model: ❑ Other specify Sguigment type and model in Section 1=on Page 2). ❑ Other(swify Cquigment nc and model in Section E on Pae 2).• Tank ID: Tank ID- ` ❑ In-Tank Gauging Probe. Model- ❑ In-Tank Gatigi g Probe. Modes; Jd Annular Space or Vault Sensor. Model: lS'� AD Annular Spr;6 or Vault Sensor. Model: ®� X Piping Sump/Trench Sensor(s). Model: St- i§ Piping Sump/Trench Sensor(s). Model; J3 Fill Sump Sensor(s). Model: •'� •Bt Fill Sump Slasor(a), Model. L - 4d Mechanical tine Leak Detector. Model: F>k9 J2L Mechanical line Leak Detector. Model: -- ❑ Electronic Line Leak Detector. Model: 13 Electronic Line Irak Detector. Model: ❑ Tank OverU/High-Level Sensor. Model: E2 Tank OverfriI/Rgh-Level Sensor. Model: ❑ Other(snify!Buipment type and model in Section E on Pae 2). q Other(s 'r'v:aa=t me and model in Section E on Pa c 2). Dispenser ID;, if 3m Dispenser ID:. -.C3 Dispenser Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Jf Shear Valve(s), Shear Valvais). O Dia enser Containment Floats)and Chain(s), O Dis nser C intainment Floats)and Chain(5). D(sptmer iA:_ 5'(® _ Dispenser ID:_ '"t'$ ❑ Dispenser Containment Sensor(s). Model:, ❑ Dispenser Containment Sensor(s). Model: AShear Valve(s). Shcor Valveis). O Dis enser Containment Floats)and Chain(s). Q Dispenser C.mainmcnt Float(s)and Chain(s). Dispenser ID: at-!Q Dispenser XD;. 11_M O Dispenser Containment Sensvr(s). Model: ❑ Dispenser C nWrment Sensor(s). Model; P Shear Valve(s). X Shear Valve-s). QDis 5enser Containment Float(s)and Chain(s). ❑ Dispenser C.,ntninment Float(s)and Chain(s). -if the facility contains more tanks or dispensers,copy this form. Include information for ee cry tank and dispenser at the facility. C. Certiliation-X certify that the equipment identified in this document was insl.eeted/servieed in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' cl ecklIsts) nccess2ry 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 2150 attached a copy of the report(check all that a Q System set-ftp ® ren it rt Technician Name(print): .. AA,A Sign--ttue: Cenzification No.: 11 License.No.: 480 ---- — Testing Company Name; Cott Co of Cal?forma _ Phone No.:( -L)t1 A95-2311 Y 385_ Site Address, n4n _, _,.,_,,— —, Date of Testing/Servicing: Page 1 of 3 Will Monitoring System Certiiicat#on