COMPLIANCE INFO_1984-2002 - Laserfiche WebLink

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MONIT�ItING SYSTEM CER, CATION For Use By AM Jurisdictions Wahirrthe State�fCowomia Authority Cited:Chapter 6.7,Nea/th and Safety Code;Chapter 16,Division 3 Title 23,California Code of ReguIxions This form must be used to document testing and servicing of monitoring equipment.A separate certification ort+eoort must be prepared for each monitoring system control panel by the technician who performs the worm A co py of this form must be provided to the tank system owner/operator. The ownedoperator must submit a 00py of this form to the local agency tegnlatmg UST systems within 30 days of test date. A. GenemlInform flon Facility Name: l// ®v L2 Bldg.No-*—L-_ Site Address: ��S� City: A,,Qjt/ ,-/V' Zip: Facility Contact Peru Contact Phone No-U Make/Model of Moaitoting Sysi6ns � /� 11 Date of Testing/Sej 2ervi .. U -� "b Iii el oor� B. Inventory of Equipment Tested/Certified S Chock ffie appropriate boa!es to indicate is equipment Tank ID: E7 q T�eln ID: fT Tank Gauging Probe. Model: ` i LrTank Gauging Probe, Medd AumularSpaoeorVatiltSensor, Model: AnnularSpaoeorvankSersot: :Medd V Piping sump/Trench Sensor(s). Model: Piping sump/Trench Seasor(s). °Model: -1/)2..cZ ❑Fill sump Seasor(s). Medd: X l Fi71 s ump Sansar(s). Model: :10 Mechanical Lace Leak Detector. Model: Line Leak Detector. Model• 41) ❑ Electronic Liao Leak Detect". Model: ❑Electronic Lae Leak Daector. Model: Tank 0vafill/Ha Model: 6aE-- Sr) ` D 9ftk uk0vafilt/Iligit Lesw . Model: ,mow G su y/z) 0 Other Lse2�fysuiemnt tm and model in Section E an Pam 2). ❑Other and model in Section E on Page 2). TankID• C1 TankID: PrIn Tank Gauging Probes Model: VP- A,1 ❑In Tank Gauging Probe. Model: Annular .Spaoc or Vault Sensor Model: ❑Annular Space or Yanit Sensor. Model: Piping Sump/Trench Sensor(s). Model: .2 d,Y ❑Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: _ ❑ Fill Sump Sensor(s). Model: -,(Mechanical Line Leak Detector. Model- 4.2 .9,6-e ❑Mechanical I.ihc Leak Model: ❑ Electronic Line Leak Detector. Model: ❑ Elec tsonic Line Leak Detector. Model: ,a Tank Overfill I IfigUAwakig. Model:a'P vv h 19 o qh/ ❑Tank Overfill I High-Level Sensor. Model: ❑ Other(s ui t type an4 model in Section E on Pa a 2). (3 Other ifyui tty1wand model in Section E on PaLe 2). Dispenser ID: ;� Dispenser ID: _ ❑ Dispenser Containment Serios). Model: ❑Du' pernsetCpnarrat s). Model: Shear Valve(s). Shear VAVC(s); EFDLspcnw Containment Floats)and Chain(s). l,?-D Containment Float( Chain(s). Dispenser ID- DispenserID• shy, ❑ Dispenser Containment Seusor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Cl DisRE=Containment Float(s)and Chain(s). ❑ RM=Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containmennt Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis ser 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 eq ' 5-=-,,ry f generating such reports,I have also attached a copy of the report;(che�au that apply): �ysteun set-up report Technician Name(print): `T• Ld&011" 2l'- Signature:� f Certification No.: 'T-Z4�� License.No.: Testing Company Name:-3 - ¢.��e/ec oreM�c��t e �, Phone No.:(��) 27 7 --7 O P.0 Site Address:25 2 k. i�-urf,�C �!u 1 dvt•bc r,� CA 9tSOS Date of Testing/Servicing: 1'a�c 1 of 3 0!m \Ia�tit<uitt_��aru�t�•rtitirttiun Y