COMPLIANCE INFO_1984-2002 - Laserfiche WebLink

Home Browse Search

.sd MONYrORING SYSTEM CERIMCATION , For Use ByAff Jurisdictions Within the State of California Authority Cited- Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California Code ofRegulations This form must be used to document•testing and servicing of monitoring equipment If more than one monitoring system control panel is installed at the facility;a-separate certification or rimort must be preyaked for. each monitorings system control panel by the technicianwho performs the work. A copy of this form must be provided to the tank system.owner/o r. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. Instructions are printed on the back of this page. A- General information Facility Name:' v t GTc.s,r Ot> t Z<( Bldg.Noy S itg Address: S_0 6 C1+4 t t.� i�'�"" City:. /�A NTt�A- P= Facility Contact Person: Contact Phone Noy Make/Model of Monitoring System: "%14 a Date ofTesting/Servicing. B. Inveiitoryof Equipment Tested/Certified Check the appropriate boxes to indicate specific'equipment' ns serviced: .- - Tank ID:. Tank ID: �4 -erin-Tank Gauging Probe. - Model: t3elre. Tank. ' Pmbe.. Medd: ' S Annular Space or Vault Sensor. Model: .K a !2 mar Space or Vault Sensor. Model: q0 V17.• ZrPipimg Sump/Trench Seasor(s� Model: ?A ' ' Snmp/Trench SeaSor(s). _ Model- ZAy=. ❑-Fill Sump Scasor(s�- - Model: ❑:FM-Sump Scasor(s). Modd: ' JB'1 =hanicd Lase Leak Detector. - .Model: .•F'k- i(z1. ine Leak DMctoa. Model:: ❑ Electronic lane Leak Detector- . . Model' O Ei;cuqdcuncL=kDctcct= Model: ❑Tank overfill/High-Level Semsor. Model: ❑Tank Overfill/S&4 cvd Sensor- ModeL-. ❑ Dispense'Containment Seasor(s). .Model: ❑.Digmser Containment Scasor(s). Model: ❑ Shear Valvc(s). ❑ Shear Vaive(s� - ❑ Disperser Contalnmcat Floats)and C hain(s). ❑Dispcaser Containment Ftoat(s)sad C2naarn(a�. . . ❑ Other(specify equipment type and model in Section E on Page 2).• ' :. ❑Other(specify equipment hype and model is Sectioai.E 4o Page 2).'•. Tank ID:_aZ Tank ID: In-Tank Gauging Probe. Model. res ❑ in-Tank Gauging Probe.', '?Aodd: Annular Space or Vault Sensor. Model: `t A _ ❑'Annular Space or Vault Sensor. Model' ,a Piping Sump/Trench Semor(s). Model- ILOS ❑ Piping Sump/Trench Sasor(s). Model: ❑ Fill Sump Sensor(s). Model: �® ❑ Fill Sump Scasor(s). Model 12-Mechanical Line Leak Detector Model: ` t 0 - ❑Mechanical Line Lcak Detector. Model: . ❑ Electronic Lane Leak Detedor. Model• ❑ Electronic Line I=k Dctator. Model: ❑.Tank Ovafnll/High-Level Sensor: Model ❑Tank overfill/ d Sensor. Model: ® DispenserContainment Sensor(s). Model• - (3 D'rspusa Containment Seasor(s) Model: ❑ Shear Valve(s). ❑Shear valve(s). ❑ Dispenser Containment Float(s)and anain(s). 0 Dispenser Containmcat Floats)and Chain(s). - E3 Other(specify equipment type and model in Seddon Eon Pap 2):. ❑Odwr(spedfy equipment type and model in Section Eon Pap 2). C. Certification-I certify-that the equipment identified in-this*document was inspected/serviced-in accordance with the manufacturers' guidelines. Attached to•this•Ceitification is iformation (eg manufacturers' checklists) necessary to verify that this information is correct and a.Site Pian showing the layout of monitoring equipment. For any.equipment• •. capable of generating such reports,I have also attached a copy of the(check all Haat i Pply): em set-up report; e"Alarm h�iistory.report. Technician Name(print): Sc Cert./Lic.No.: Signature: 1. .,. .. '".T'.-r a o�.....�•tr,.-(�t�'i 1�C•l�..�Ir17 t�